.<>% 






v^' -^y.. 



^ » ft "• ,\\ \ \ B 



*^ 









^■^ .V...-^ 






7^ -^ 



^^O\o0 



.\-;^^i:^ 






' \>^. 



^^ 



' 'f*. 






.V 



<^ 'f 


















0( 



^ -?=•. 










""-i^^/-.^'- N 


-- - \ 






' '' * ^ s "^ ., 


>. * ^u 






.-^'^ 


0°' ■ 




K 




0^ r 






^^ l^ 


X*"^ ^«t- '* 






^6, ^ 


;- ->. 






^''^^:o 








^^/. -^. 




^<^s'- 




: ^.^ 




A. ,r^ 




. S -^'^ 





^/ .-^ 



/^^ 



'^.p^^^^' 







■% 




















<^ 



^ ' * " ' o'^ 



THE 



PHILADELPHIA 



PRACTICE OF MIDWIFERY 



BY / 

/ ■ 

. CHARLES D. MEIGS, M.D. 

l.ECTUREK ON MIDWIFERY AND THE DISEASES OF WOMEN AND CHILDREN J MEMBER 

• OF THE AMERICAN PBILOSOPHICAI, SOCIETY; AND OF THE ' 

PHILADELPHIA.MEDICAL SOCIETY. 



WITH NUMEROU-S ENGRAVINGS. . 



-■'A':----- 



PHILADELPEIi^,: -. . 

JAMES KAY, JUN... & BROTHER, 122 CHESTNUT STREEt. 

■ •• PITTSBUUGH: J O UN" .1 .• K AY & CO. 



l^ 



M.^ 






Entered according to the act of congress, in the year 1838, by James Kay, Jun. & 
Brother, in the office of tSie clerk of the district court of the United States in and for 
the eastern district of Pennsylvania. 



3 ^^/ 



TO 



RENE LA ROCHE, M.D 



My dear La Roche : 

I dedicate my book to you, and it is due to you 
that I should explain the motives which have led me to 
its publication. I shall, therefore, state very briefly, 
that, having for several years been engaged in delivering 
lectures on Midwifery and the Diseases of Women and 
Children, in this city, I have been repeatedly asked to 
publish a volume on Obstretric subjects, adapted to the 
use of students of onedicine ; and engaged, in conse- 
quence of a written request from members of my class 
in the Philadelphia School of Medicine, to make a publi- 
cation upon subjects connected with my course of lec- 
tures. 

Inasmuch as I had very often gone over with my 
classes the consideration of the principal topics bearing 
on this branch of medical studies, 1 thought myself suffi- 
ciently informed upon all the theoretical parts of it to 
warrant me in undertaking to write for the use of begin- 
ners, at least ; and felt assured that my opportunities for 
acquiring clinical knowledge were such, that, if they 
should have been properly improved, they could not but 
have qualified me to express my thoughts in this way. 

The volume is so small that you will not expect to 
find in it full and copious details on all the subjects 



^'^'■^ 



IV DEDICATION. 

usually treated of. I have been obliged to make some 
of the articles so very brief, as to render them less useful 
than they ought to be, or perhaps absolutely meagre. 
Nevertheless, the directions which will be found here 
are such as I have had reason to approve of, upon 
a good share of experience and reflection : and, as I 
wrote principally with the expectation of affording some 
help to the student of this important department of our 
profession, I sincerely hope that he may find the expla- 
nations and directions wortliy of his confidence, and, in 
some measure, conducive to his advantage. 

It may, perhaps, be said that we do not want any more 
works on Midwifery, or, at least, systematic works. 
I admit that the valuable publications of Dr Dewees 
might serve as a reinforcement to such an objection. 
There is also the work of M. Velpeau, which I trans- 
lated from the French, and published in this city a few 
years ago : a work so excellent, that it has almost be- 
come a text-book, as I am informed. These, and seve- 
ral new publications in England and Ireland, might have 
served as inducements for me to avoid troubling my bre- 
thren with the offer of this volume, perhaps an additional 
burthen to their book shelves. However, having con- 
densed, as far as I could, the several subjects treated of in 
it, and having made it rather an expression of my own 
reflections and experience, than a dry compilation of ma- 
terials to be found everywhere in the Obstetric libra- 
ry, I venture to offer it to ray brethren, especially the 
younger among them, in the hope that at least some 
parts of it may not be found wholly devoid of interest, 
nor to be perused without profit. To you, my kind 
friend, I ofi'er it, with the confident hope that you will 
pardon its faults. I most sincerely wish it were far 
more worthy of your acceptance; or fit to be a measure 
of the esteem and afleciion of 

Yours, 6zc. 

CHARLES D. MEIGS. 



CONTENTS. 



CHAPTER I. 

THE PELVIS consists of the sacrum and coccyx, and two 
ossa innominata. Ossa innominata, composed of two ossa ilia, 
two ossa ischia, and two ossa pubis. The division of the inno- 
minata. The pehds a basin, 1. The upper and lower basins ; 
separated by the superior strait, or margin, called also the brim, 
or linea ileo-pectinea. The excavation, how formed ; deeper 
behind and on the sides than in front. The outlet or inferior 
strait, 2. The upper basin described ; its uses. Poupart's liga- 
ment a part of the basin. The plane of the superior strait, 3. 
The importance of adjusting the plane of the superior strait in 
midwifery practice. The plane of the inferior strait. The axis 
of the pelvis, 4. The axis of the excavation. The sacrum — its 
situation — exposure — its curve — its foramina, 5. A knowledge 
of the foramina of the sacrum useful as a means of diagnosis. 
The coccyx — not easily forced backwards in labour. The ischium 
— its pelvic face — a triangle — a plane, 6. The inclination of the 
plane, 7. The pubis — its rami — ligaments. Its arch. The sacro- 
sciatic notch and ligaments, 8. The diameters of the pelvis. Four 
diameters for the superior strait. Two diameters for the inferior 
strait, 9. Table of pelvic diameters, 10. The sacro-iliac junc- 
tion strengthened by ligaments behind, but dependent for secu- 
rity in front on the pubic symphysis. The separation of the pu- 
bis admits of an opening of the sacro-iliac junction. The symphy- 
sis pubis. The triangular ligament, the crown of the pubic arch, 
11. The symphyses do not open in labour, except morbidly, 12. 
1* 



MM 



TI CONTENTS. 



CHAPTER II. 

THE CHILD'S HEAD. The bones not firmly united. The 
head plastic. Its diameters — as oblique, horizontal, transverse ; 
and the perpendicular diameter, 13. In labour one of the extre- 
mities of the head must present. These are the vertex and chin. 
Example of face presentation, 14. The fontanels — how distin- 
guished. The anterior or frontal fontanel the largest. Inconve- 
nience arising from firm ossification of the head, 15. 

CHAPTER III. 

THE DEFORMED PELVIS. Excessive amplitude. In 
what manner inconvenient, 16. insufficient amplitude of a sym- 
metrical pelvis, 17. Deformity from rickets and malacosteon. 
The long bones afiected as well as the pelvis. The softened pel- 
vis admits of the sacrum sinking down under pressure, towards 
the pubis, 18. The new forms of the pelvis very various. The 
lower strait may be vitiated aione. A straight or very curved sa- 
crum, 19. Deformed by exogtosisj and by convergent spines of 
the iScbia, 20, 

CHAPTER IV. 

THE ORGANS OF GENERATION. External, internal, 
21. The necessity of studying their anatomical characters. The 
mens. The vulva. The labia majora. The looseness of their 
texture and liability to distention, by blood, or water, or inflam- 
mation. Their extensibility in labour. Sometimes broken ofi", 
23. The labia filled with blood after labour, how treated. When 
infiltrated with serum, how treated. Abscesses generally suppu- 
rate ; why, 24. Cohesion of the labia in children. The scal- 
pel not necessary to destroy the cohesion, 25. The nymphoe. 
Their structure and uses. They are not eflfaced in the last mo- 
ments of labour, 26. Subject to painful inflammation. They 
are enlarged. Excised, 27. The clitoris. Its preputium. Its 
universal occurrence in mammalia, except the duck-billed ani- 
mal. Hypertrophia of the clitoris, 28. Salmacis and Hermaph- 
roditus. The vestibulum. The urethra. The female catheter, 
20. Sloughing of the urethra; of a large part of the bladder, 30. 
The hymen, 3L The fossa naviculaiis. The perineum, 32. 



CONTENTS. Vll 

Resistance of the perineum in labour; and laceration, 33. Ne- 
cessity of supporting the perineum in labour, 34. The vagina. Its 
structure. Cicatrices, 34, 35. The uterus; how supported, 36. 
Its broad ligaments. Its tissue not fully understood by anato- 
mists, 37. Its size in the non-gravid and gravid states, 38. Mode 
of action of the womb in labour, 39. The Fallopian tubes, 40, 
The ovaria, 41, 

CHAPTER V. 

MENSTRUATION. Peculiar to the human female, 42. Re- 
gularity of the menstrual office, 43. Importance of the catame- 
nial office, 44. Influence of the ovaria. Comparison of the male 
and female, 45. Comparison of the menstrual act with the erotic 
seasons of the mammalia. The proximate cause of the periodi- 
city, 46, 47. Remarks on plethora as an assumed cause, 48. On 
lunar influence, 49. The menses secreted by the womb. The 
fluid does not come from the veins, 40. Women who menstruate 
in pregnancy, 51. Nature of the fluid, 52. Effects of coagula 
in menstruation, 52. Periods of eruption various in different 
countries, 53. Period of cessation. Its phenomena, 55. jPangers 
incident to this crisis, 56, 

CHAPTER VI. 

AMENORRHCGA. Emansio and suppressio mensium. 
Causes of amenorrhcea, 57, 58. Necessity of attending to the 
state of the system, 59. Dependence of menstruation on the 
state of the circulation. Influence of the liver and portal sys- 
tem. Of the skin. Dress, 60. Emmenagogues, 61. The em- 
menagogues not worthy of great confidence, 62. Dr Cullen's 
opinion of them, 63. 

CHAPTER VII, 

DYSMENORRHCEA. Various grades of it, 64. Causes of 
the malady, 65. Caducous secretion. Engorgement and mor- 
bid sensibility of the womb, 66. Effects of rest in dysmenorrhoea. 
Of venesection; aperients; alteratives; diet, 67. The bath. 
Dress. Dr Mackintosh's mode of treating dysmenorrhoea by 
the bougie, 68. 



VIU CONTENTS. 

CHAPTER VIII. 

LEUCORRHCEA. All secreting organs liable to morbid al- 
terations of their products, 70. Vigarou's description of leu- 
corrhoea, 71. The leucorrhoeal product formed either in the 
uterus or vagina, 72. Causes of it, 73. Leucorrhoea affects the 
health, not on account of the quantity of the discharge, but be- 
cause the disease is uterine, 74. Danger of attributing it always 
to weakness, 74. The necessity of the touch in rebellious cases, 
and of attending to the state of the system, 75. Rest — its in- 
fluence. Purging. A regulated diet, 76. Cleanliness. Injec- 
tions. Anodynes, 77, Prescriptions, 78. 

CHAPTER IX. 

PREGNANCY. Of reproduction, 80, 81. Theories of repro- 
duction, 83. Buffon's theory, 85. Epigenesis, 88. Animalcu- 
lists, 89. Harvey, Graaff, Spallanzani, 92. Spallanzani's ex- 
periments, 94. The cicatricula of the egg, 96. The ovarian 
vesicle or germ. The decidua, 100. Formation and use of the 
decidua, 101. The ovule reaches the womb — and its place of 
attachment becomes the placenta. No part of the placenta de- 
rived from the v/omb. The chorion is its source, 102. The am- 
nion and the umbilical vesicle, 103. Probability that the true 
germ is betwixt the chorion and amnion. Liquor amnii. Its 
uses, 104. The position of the embryo ; surrounded by the waters. 
105. Gradual development of the gravid womb. State of the 
cervix at different stages. Thickness of the walls of the womb. 
Its vascularity, 106. Case exemplifying the contractility of the 
OS uteri. Variety of opinion as to the arrangement of the mus- 
cular fibres, 107. Their co-ordinate contraction constitutes la- 
bour. Thickening, 108. The womb generally oblique in preg- 
nancy, 109. Effects on the system of very great tone of the 
abdominal muscles in pregnancy, 110. Headach, vertigo, 
dyspnoea and cough ; varices and oedema produced by it, 1 11. The 
after-birth, 112. Its attachment very slight, 113. The secun- 
dines of the mammalia, 114. No considerable vessels passing 
from the placenta to the womb. Explanation of the effusions of 
blood in detachment of the placenta. Does not always occur, 115. 
The structure and uses of the placenta; dependence of the foetus 
upon it, 116. The placenta the medium of the nutrition of the 



CONTENTS. IX 

foetus, 117. Foeto-placental circulation, 118. Development of 
the fcEtus more rapid in some women than in others. The dura- 
tion of pregnancy, 280 days. Dr Merriman's observations on the 
duration of pregnancy, 120. Experiments of Mr Tessier. The 
child quickens in the twentieth week, 121. Formation of the 
septum auricularum, 122. Signs of pregnancy, 122. Touch and 
ballottement, or tilting, 123. Auscultation. The soulSle, 124. 
jNecessity of distrusting complaints of amenorrhcea, 125. To 
procure abortion is a felony. Abortions, 126. Causes of miscar- 
riage, 128. Hemorrhage attendant upon abortion. Management 
of it. The tampon, 129. Abortion, with the ovum retained, 130, 
Care required in the use of the plug, 131. Prolapsus produced by 
abortions, 132. Prolapsions, 133. Singular symptoms produced 
by prolapsion — with cases, 134, 135. Pessaries, 136. Retrover- 
sion, 141. Position of the patient in an attempt to reposit a retro- 
verted womb, 145. Preparation of a patient for labour, 147. 

CHAPTER X. 

LABOUR, 149. Baudelocque's theory of the cause of labour, 
151. The sinking downwards of the womb at the close of preg- 
nancy, 152. Labour-pains. Their influence on the economy, 
153. They excite the blood-vessels and heart, 155. The touch, 
156. False pains, how distinguished from true, 157. Injurious 
effects of over-distension, 158. In the progress of labour the os 
uteri descends, but rises again when the head has escaped into 
the vagina, 159. Sketch of the process by which the ovum is 
expelled, 159, 160. The bag of waters, 160. The chin of the 
child is brought to its breast. Causes of this flexion, 161. Rea- 
son why the head enters obliquely into the pelvis. Positions of 
a head-presentation, 162. Table of positions from Boivin, 163. 
Mechanism of labour. The head. The shoulders, 164; 165. Size 
of the womb after labour, 166, 

CHAPTER XL 

CONDUCT OF A LABOUR, 167. Table of the duration 
of 839 labours, 168. Duties of the accoucheur in his inter- 
course with the patient, 169. Necessity of attending to the circu- 
lation — which ought to be excited during labour. A natural degree 
of excitement not to be prevented, 170. Case where the pulse was 
sixty-five during a whole labour. Dr Dewees's opinion on copi- 



X CONTENTS. 

ous bleeding in parturition, 171. Of the use of enemata and 
aperients in labour, 172. The diet ; effects of on labour, 173. Of 
the patient's attitude. Obviates obliquity of the womb, 174, 175. 
The dip, or flexion of the head, to be provided for, and the means 
of doing it, 175, 176. The rotation of the head— it fails, why. 
How to remedy it, 177. Delivery of the head sometimes pre- 
vented by the grasp of the cervix, which was supposed to be 
completely dilated, 178. Effects of a very straight sacrum on 
rotation. The head escapes in a transverse position. How this 
is effected. Too deep a curve of the sacrum; its effects, 179. A 
narrow arch. Resistance of the perineum, 180. The danger of 
rupture of the perineum to be obviated — why and how, 181, 182. 
The cord twined round the child's neck, 182. The delivery of 
the shoulders. The body not to be dragged out, 183. How to 
treat the child. Tying the cord. How to hold it, 184. Manage- 
ment of the placenta, 185. Where the placenta is retained, 186. 
The placenta sometimes retained. Method of delivery, 187. Af- 
ter-pains, 189. A relaxed uterus bleeds. A contracted one does 
not admit of a flooding, 190. Concealed bleeding. Case, 191. 
Effect of position in uterine hemorrhage. Dr James's case of 
flooding, 192. Use of ergot to prevent flooding. Means of ob- 
viating concealed hemorrhage, 194. Women faint from want of 
mechanical support to abdomen after delivery. Case of Mrs I. 
A. S., 196. Diet of an accouchee. Treatment of the child, ]97. 
Sitting up. Of medicines for lying-in women, 199. 

CHAPTER Xn. 
FACE PRESENTATIONS 201 

CHAPTER Xni. 

ON THE POSITIONS OF THE HEAD, AND THEIR 
MECHANISM, IN LABOUR, 216. Of the touch or exami- 
nation, 218. Presentations and positions — their difference, 221. 

CHAPTER XIV. 

ON PRESENTATIONS OF THE PELVIC EXTREMI- 
TY OF THE FCETUS, 228. Causes of breech presentations; 
not a preternatural labour, 229. Causes of the danger to child, 
230. Proportion of cases fatal to child, 231. Mode of diagnosis, 



CONTENTS. XI 

232, The feet not to be brought down, 233. Positions of a 
breech presentation. Management of the case, 235. Care re. 
quired in delivering the head, 239. The author's custom to pro- 
vide forceps in all cases of pelvic presentation, or other kinds, 
where the head is last to be born, 238. Delivery in breech cases, 
where the sacrum is towards the mother's back, 238. Cases, 
240, 241. Presentations of knees and feet, 242. 

CHAPTER XV. 

ON PRETERNATURAL LABOUR, 241. The shoulder 
presents, 245. Shoulder positions, 247. Diagnosis; it must be 
turned, 248. The method, 249. The operation, 250. Labour 
with hemorrhage, 255. Observations on these cases, and the ge- 
neral means of treatment, 256, 258. Louisa Bourgeois's method, 
259. Placenta proevia, or unavoidable hemorrhage, 261, 262, Ci- 
tation from Dr Collins, 263. Delivery in placenta praevia, 264. 
Concealed hemorrhage, 266. Hemorrhage after the delivery of 
the child, and before that of placenta, 267. Adherent placenta, 
268, Hour-glass contraction, 269. Hemorrhage after delivery 
of placenta, 270. Case from Mauriceau, 271. Preternatural 
labour from convulsions, 277, 282. Prolapsion of cord, a cause 
of preternatural labour, 283, Fainting, a cause of preternatural 
labour, 284. Hernia, 285. 

CHAPTER XVL 

OF THE FORCEPS, 286. Ancient resources, 287. Doctor 
Chamberlayne, 288. His case with Mauriceau, 289. The old 
curve and the new. Smellie and Levret, 290. Pean, or Baude- 
locque's forceps, 291. Dr D.Davis's forceps, 293. Action of 
the forceps, 294. It is designed for the head alone, 297. Rules, 
298. Application of the forceps, and its use, 299, 305. Applica- 
tion where no rotation takes place, 305. In the second position, 
306, With vertex to sacrum, 307. In the fourth or fifth, 308. 
Transverse head, 309, 310, Forceps in face cases, 311, Locked 
head, 312. Impaction, 315, Forceps applied to the head in the 
last stage of footling cases, 315^ Craniotomy, 317. Observations 
on embryulcia, 317 to 322. Case of Mrs R., 322—334. Remarks 
on the crotchet, 335. Instruments for delivery in deformed 
pelvis, 336, 



Xll CONTENTS. 

CHAPTER XVII. 
INVERSION OF THE WOMB 340 

CHAPTER XVni. 
PUERPERAL FEVER 345 

CHAPTER XIX. 
ATRESIA VAGlNiE c 360 



CHAPTER I 



THE PELVIS. 



The Pelvis consists of an irregular canal, composed 
of four bones, that are firmly united, in the adult, by what 
are called the symphyses. These bones are, 1st, the 
sacrum; 2d, the coccyx, which is attached to the lower 
end of the sacrum; 3d, the two ossa innominata or hip 
bones, which are united to each other, in front, by the 
pubic symphysis, and behind, to the right and left sides 
of the sacrum, by what are denominated the sacro-iliac 
symphyses. When bound together by their natural liga- 
ments, they might, by a careless observer, be mistaken 
for a single bone, but, a slight inspection will suffice to 
show the points of their union which have been just^ 
mentioned. 

The ossa innominata are, further, divided, for the con- 
venience of reference, into portions ; namely, three por- 
tions for each os innominatum. They are the os ilium, 
OS ischium, and os pubis ; the several limits or boundaries 
of which may be discovered by examining the pelvis of 
a young subject, in which the ossific growth is not 
completed. The division lines of the three portions 
meet nearly in the centre of the acetabulum, giving the 
upper and outer two-fifths to the ilium, one-fifth ante- 
riorly to the pubis, and the remaining two-fifths to the 
ischium. 

The bony pelvis may be compared to a basin with part 
of its edge or side broken out ; for the crista of the ilium 



3 THE PELVIS. 

advances scarcely beyond the transverse diameter of the 
bowl, leaving a vacant space in front, which in the living 
subject is occupied by the abdominal muscles. See the 
figures of the pelvis. The sides of the basin are composed 
of the costse of the ilia, and the back part is filled up by 
the lumbar vertebrse : thus representing, as I have said, a 
bowl with its side broken out. The pelvis is commonly 
divided into the upper and lower basin — the division be- 
twixt the two being clearly marked by a line, margin, or 
brim, running right and left, round the sides and back of 
the pelvis, from the top of the pubis to the front of the 
articular surface by which the sacrum is joined to the last 
lumbar vertebra. This line is denominated the linea 
ileo-pectinea, or ileo-pubic line. It defines the superior 
strait. 

Upon looking downwards into the pelvis, below the 
linea ileo-pectinea or superior strait, a cavity is perceived, 
which is called the lesser basin, or, more properly and 
"echnically, the excavation. The excavation is bounded 
above, by the linea ileo-pectinea, behind, by the sacrum 
and coccyx, on the sides by the ischia, and in front by 
the pubis. As the sacrum, with its appendage, is more 
than five inches long, the ischia three and a half inches, 
and the pubis only one inch and a half in length, it is 
evident that the excavation is much deeper behind and 
on the sides, than in front. The finger can reach above 
the strait in front, whereas the hand must be introduced, 
to reach up to the top of it behind. 

The outlet of the pelvis, called the perineal or inferior 
strait, is bounded by the under and inner edges or lips 
of the pubes, ischia and coccyx, In the dried pelvis it 
is of a most irregular shape, furnishing, in front, a large 
notch called the arch of the pubis, and two very deep 
indentations or notches in the sides, which have received 
the appellation of sacro-ischiatic notches, because they 
occur between the sacrum and ossa ischia. 

From the foregoing it appears, that we assign to the 
pelvis an inferior strait, an excavation, and a superior 
strait, all of which are comprehended in the term lesser or 
lower basin ; while on all that portion of the organ which 



THE PELVIS. 3 

is found above the ileo-pubic line, is conferred the title 
of superior basin or upper pelvis. 

The upper basin of the pelvis is bounded above, by the 
cristae of the ossa ilia. The anterior extremity of this 
crista or rim, is called the anterior-superior spinous pro- 
cess, while a little below it, is observed the anterior-infe- 
rior spinous process. The ilium terminates, behind, in a 
posterior-superior spinous process, and has, a little lower 
down, a posterior-inferior spinous process. The bone 
exhibits an articular surface, placed in an oblique direction, 
near its hinder extremity; this surface is tipped with 
cartilage, that is in contact, in the recent subject, with a 
similar plate of cartilage upon the sacrum, at the point of 
their junction, the sacro-iliac symphysis. 

Th3 broad thin portion of the ilium, looking upwards 
and inwards, is the costa, or iliac fossa. It is in this 
concave part of the bone, that the child's head or other 
presenting part, is placed temporarily, whenever it be- 
comes necessary to push that part away from the upper 
strait, in order that the accoucheur's hand may pass up- 
wards into the womb, to seek for the child's feet, in 
turning. This seems to be one of its chief obstetrical 
uses ; since the head can not be pushed backwards, be- 
cause of the vertebrae, nor readily in front, on account of 
the resistance of the muscles ; so, when the head rests on 
the strait, or within it, the accoucheur's hand, in order to 
pass upwards through the strait, must first of necessity 
remove the head into some other position. Poupart's 
ligament, which extends from the anterior-superior spi- 
nous process of the ilium to the pubis, also in some 
measure prevents the head from being pushed out of the 
way towards the left or right front, and is by some per- 
sons considered as composing part of the limits of the 
upper basin. 



In order to get a good idea of the plane of the superior 
strait, let a half sheet of paper be cut in such a manner 
as to fit within the linea ileo-pectinea, and when placed 
therein, it will represent that plane. Hold the pelvis in 






4 THE PELVIS. 

such an attitude as it occupies in an individual standing 
up or sitting, and it will be found that the plane of the 
strait dips at about thirty-five degrees, an inclination 
which is increased or diminished, at will, by extending 
or flexing the lumbar vertebrae. 

In the practice of midwifery, it is often a matter of 
great importance to attend to the degree of inclination of 
this plane. Let us suppose a child lying within the 
uterus, and destined to pass downwards through the 
pelvis : if the plane of the superior strait be excessively 
inclined, the presenting part of the child would be pro- 
pelled upon the top of the pubis, or even over and above 
it — a case that is not unfrequently met with; whereas, if 
the inclination be just or natural, the presenting part 
enters the opening withvout such impediment. To a 
practitioner unacquainted with the indications derived 
from the state of inclination of this plane, much embar- 
rassment is likely to accrue, ac long as he remains igno- 
rant of the reason which prevents the engagement, as it 
is called, of the head from taking place. 

If a piece of paper be fitted into the lower strait in like 
manner with that above mentioned, it will represent the 
plane of the inferior strait : upon comparing them, they 
are found to be very much inclined towards each other, 
being distant from each other one inch and a half in the 
front of the excavation, and five inches and a half behind. 



If a piece of wire be now passed perpendicularly 
through the centre of the piece of paper that represents 
the plane of the superior strait, it will represent the axis 
of that strait. And if another wire be pushed through 
the centre of the plane of the inferior strait, and per- 
pendicularly to it, it will be the axis of the inferior strait. 
The upper wire will strike the sacrum pretty low down, 
or towards its point; and the lower wire will strike the 
same curve pretty high up towards its base ; all of which 
shows, conclusively, that the axis of the superior is 
diff'erent from the axis of the inferior strait, or what 
comes to the same thing, that the canal of the pelvis is a 



THE PELVIS. 5 

curved one, and that the child in passing out must proceed 
through a curved, and not a straight canal. If the upper 
wire were bent, and pushed through the upper plane, and 
carried downwards until it passed through the centre of 
lower plane, it might then represent a curved axis of the 
curved canal; it would be the axis of the excavation. 



If the reader will now take into his hand a sacrum, 
he will see that it is a triangular bone, with the apex 
downwards, and the base upwards. At the base is an 
articular surface, by which it was joined to the last 
lumbar vertebra ; and on each side is an articular surface, 
by which it was united to the innominata, as before men- 
tioned: these facettes are so placed that, it will be at once 
evident, the sacrum could not be driven downwards with- 
out riving open the innominata, for it enters them like a 
wedge ; nor could it be driven outwards without also 
riving them asunder ; so that it is in a manner dove- 
tailed into the coxalia ; a very wise provision of nature ; 
for, all the forces t?jat naturally operate on it, tend to 
drive the sacrum either downwards or outwards ; as, first, 
the weight of the body, and second, the pressure of the 
foetus during the parturient throes. These are the only 
forces to whose displacing action it is much exposed. 

The sacrum is about four inches long, and when the 
coccyx is added, the whole length is at least five inches. 
If a ruler be placed so that it may touch the top of the 
sacrum and the point of the coccyx at the same time, it 
will represent the chord of an arch, the arch being 
formed by the curve of the sacrum, the deepest part of 
which curve will be found about midway between, but 
rather nearer the top than the bottom, and at least half 
an inch in depth, in an average of cases, notwithstanding 
that some specimens are found, in which the curve is 
either much greater or much less. All deviations from 
the average measurement exert a more or less unfavour- 
able influence upon the progress of a labour. 

Upon each side of tlie hollow of the sacrum may be 
observed a row of holes, which transmit nerves from the 



6 THE PELVIS. 

lower end of the medulla spinalis. They are generally 
five in number upon each side. The situation of these 
nerves exposes them to severe pressure during the transit 
of the child's head over their foramina; and, as in other 
cases of pressure upon a nerve, the parts to which they 
are distributed, become affected with severe cramp or 
numbness, which generally vanishes as soon as the 
pressure ceases, but, not unfrequently, continues long 
after the termination of the labour, in consequence, per- 
haps, of the nerve having been severely contused and 
injured. 



The coccyx is attached to the apex of the sacrum 
by a joint, which is said to admit of the point of the 
bone moving back half an inch when pressed by the 
foetal head. I think, however true it may be that the 
coccyx moves backwards when hard pressed, that this 
does not occur as a common or ordinary event. This 
seems to be established upon a reference to the situation 
of the sacro-sciatic ligaments, which fasten the coccyx 
so firmly to the os ischium that it requires a severe strain 
to move it backwards as far as is pretended. I have had 
several occasions to observe, that where the coccyx has 
been violently pressed backwards in labour, great pain 
and inconvenience have resulted from the accident, the 
symptoms being not very dissimilar from those which 
occur after falls upon the point of the bone. 



The ossa ischia, whose situation has already been 
pointed out, merit the attention of the student of this 
important portion of obstetric anatomy, particularly as 
regards the appearance and influence of their inclined 
planes, of which so much is said in books of midwifery. 
The inner face of the ischium is nearly an equilateral 
triangle, and is three and a half inches in length ; the 
surface is smooth and level, so that a ruler, laid upon 
it, touches it throughout. From the posterior side of the 



THE PELVIS. 7 

triaugle proceeds a strong process called the spinous 
process of the ischium, which furnishes a place of attach- 
ment for the lesser sacro-ischiatic ligament. The lower 
portion of the bone is rough and very thick, constituting 
the tuberosity of the ischium, the part upon which the 
body rests when in a sitting posture. A process 
springs upwards, forwards, and inwards from this point,, 
to meet and unite with a like portion sent down from the 
pubis ; it is the ramus of the ischium. The planes of 
the two opposite iscliia incline towards each other for- 
wards and downwards ; in order to get a good idea of 
this inclination, let the student take a pair of compasses, 
and measure with them the transverse diameter of the 
superior strait, the legs resting upon the linea ileo- 
pectinea respectively. They will be found at least fou 
and a half inches apart. But if they be now transferred 
to the transverse diameter of the lower strait, a leg of the 
compass resting upon the inner lip of each tuber ischii, 
they will be four inches apart ; proving that the inclina- 
tion of the planes causes them to approach at least half an 
inch in the course of their descent of three inches and a 
half from top to bottom of the sides of the pelvis. The 
posterior angles of the ischia are also much farther apart 
than their anterior. If two slender rods, eighteen inches 
long, be laid along the faces of the ischia, one on each, in 
a dried pelvis, and the lower ends of the rods be allowed 
to project below, they will cross each other about thir- 
teen inches below the outlet. The effects produced by 
this arrangement of the inclined planes will be discussed 
in a subsequent page. 

But while the surface of the ischium is level, that of 
the sacrum is very much curved, being farther from the 
pubis, by at least half an inch, at its middle, than at either 
its base or apex, a circumstance of the utmost importance 
in what is called the mechanism of labour. It is this 
curve of the sacrum, that gives to the lesser basin its 
specific character as " excavation." If the sacrum were 
straight, as the ischia are, there could be no excavation, 
the canal would be conical ; a glance at the pelvis, or the 
figures, shows this conclusively. 



asffiii-TTiyri,.— 



THE PELVIS. 



It should now be observed, that the pubis sends off an 
horizontal portion to unite with the ilhira and ischium 
in the acetabulum, and a descending ramus to meet the 
ascending ramus of the ischium, which it meets half 
way. These horizontal and descending portions leave 
an oval opening called the foramen ovale, which, in the 
recent pelvis, is filled with a membranous ligament called 
the obturator membrane, giving origin to muscles, and 
passage to vessels and nerv^es. The descending rami of 
the ossa pubis are connected together, towards their 
origin, by a ligamentous matter, which, from its shape, is 
called the triangular ligament, and is a part of the inter- 
pubic ligament, which not only binds the two pubes to- 
gether, but also serves to render the arch of the pubis 
broader or lower, as well as stronger. The anterior 
edges of the rami are turned outwards, as if some hard 
body had passed through the pelvis, and squeezed them 
out, while in a soft and plastic state. This conformation 
admits of their retaining the requisite degree of strength, 
while it also allows the opening through which the child 
is to pass, to be sufficiently large and free ; a singular 
proof of the wonderful adaptation of the organs, in early 
life, to the functions they are destined to perform at a 
more advanced period of existence. 



The sacro-sciatic notch is partly occupied by two liga- 
ments : one proceeding from the edge of the sacrum to 
the tuberosity of the ischium ; and the other from the edge 
of the sacrum, and coccyx, to the spine of the ischium ; 
the former is the outermost one. Hence it is seen, that 
the lower strait of the pelvis, in the recent subject, is 
marked by the point of the coccyx, the inner edges of 
the tuberosities and rami of the ischia, the inner edges 
of the arch of the pubis, and the inner edges of the sacro- 
sciatic ligaments. 

From all the foregoing, the student cannot fail to have 




Llnar.»niriiririij,&Mfrt 



tMrneoBmrn 



THE PELVIS. 9 

acquired an idea of the planes of the pelvic straits ; 
the inclined planes of the ischia ; the superior strait ; 
the inferior strait ; and the great space between them, 
called properly the excavation. He will see, therefore, 
that the child's head may be engaged in the superior 
strait ; it may be entirely in the excavation; or again, it 
may be engaged in the inferior strait ; and that the pro- 
cesses he should institute in conducting a labour, will be 
modified by its situation with regard to these several 
points. The figure exhibits the curve of the sacrum^ 
the plane of the ischium, and the inclination of the plane 
of the superior strait. 



The diameters of the pelvis are certain lines supposed 
to cross its straits ; but the practitioner ought to be not 
less familiar with the diameters of the excavation, than 
with those of the straits, notwithstanding we commonly 
understand them as referring only to the straits. 

For the superior strait are reckoned four diameters : 
1st, the antero-posterior diameter, extending from the 
symphysis pubis to the projecting top of the sacrum, 
in length four inches ; 2d, the transverse diameter, ex- 
tending from side to side, which is four and a half or 
five inches ; and 3d and 4th, the two oblique diameters, 
extending from the sacro-iliac symphysis on either side, 
to the ileo-pubal line, opposite to the acetabula. They 
are each five inches; but in the recent subject, the trans- 
verse diameter is lessened because of the psoae and iliac 
muscles, which overhang the sides of the brim. See 
the cut, which represents the opening, or superior strait. 

In regard to these diameters, it is proper to be under- 
stood, that they are the average results of the measure- 
ment of many pelves, and cannot be taken as the inva- 
riable dimensions of the female pelvis ; for all are not 
alike, some being as much as five inches in their antero- 
posterior line, and others less than four inches. Let it 
be understood, therefore, that a well-formed pelvis has 
such dimensions as have been above assigned. 

To the inferior strait, only two diameters are com- 



10 



THE PELVIS. 



monly attributed : namely, a transverse and an antero- 
posterior diameter. The trans v^erse one is estimated at 
four inches, and extends from the inner edge of the 
tuberosity of one ischium, to that of the other. - The 
antero-posterior one is measured from the inner edge 
of the top of the pubic arch, to the point of the coccyx; 
it is four inches and a half, but may possibly be rendered 
larger by the regressive motion of the coccyx, which, in 
consequence of its articulation with the sacrum, may 
admit of its apex being thrown backwards half an inch 
when under very severe pressure. See the figure of the 
inferior strait. 

I have subjoined a tabular view of the pelvic diame- 
ters, taken out of several authors, which will give the 
reader the advantage of seeing, at once, that nothing is 
absolutely settled upon this point, since so many distin- 
guished writers differ from each other in their statements 
of them. 



Pelvic 
Diameters. 


S 
m 


CO 

c 

D 


6 
s 
cr" 
o 

© 
-a 

3 
C3 

cq 


c 
.2 

a 

o 


2 

3 

o 


c 


Qi 
& 

O 


< 


A. posterior 


4i 


4 


4 


4 


4 


4 


+ 4 


4 


Transverse 


5i 


51 


5 


5 


5 


5 


+ 5 


5 


Oblique 





H 


^ 


4i 


4to4| 


4 


+ 5 

+ 4 


5ito5i 
5 


Coccy-pubic 


5 


5 


4 


4 


[schiatic 


H 


4 


4 


4 


4 


4 


=5 


4 



The articulation which conjoins the sacrum and ilium, 
is called the sacro-iliac junction, or symphysis. Each 
of the bones has a covering of cartilage, and is secured 
by certain powerful ligaments, which are found on the 
exterior of the pelvis. They are further bound together 




10 



THE PELVIS, 11 

by the sacro-sciatic ligaments before mentioned, two in 
number; namely, an outer or greater sacro-sciatic liga- 
ment, passing from the inferior and posterior portion of 
the ilium and the edge of the sacrum and coccyx, to the 
tuber ischii; and an inner or lesser sacro-sciatic liga- 
ment, arising from the edge of the coccyx and sacrum, 
and inserted into the spine of the ischium. The lines 
of these fibrous bands cross each other obliquely, but 
are in a measure fused by fibres which pass from each 
to the other, interchangeably. They are very strong, 
and add much to the security of the articulation. 

The anterior part of the sacro-iliac symphysis is not 
protected by any ligament of considerable size, except 
the anterior sacro-iliac, although covered by some fibrous 
bands additional to the periosteum. As the principal 
sacro-iliac ligaments are placed on the outer margin of 
the joint, the symphysis would be liable to open, were 
it not completely subjected and controlled by the liga- 
ments which compose the symphysis of the pubis ; and 
in fact, when the symphysis of the pubis is ruptured or 
cut, it is found that the sacro-iliac symphysis immedi- 
ately opens to a considerable extent, the bones of the 
pubis separating, without any artificial force, fully half 
an inch. The effects produced by riving open the 
sacro-iliac joint may be readily conceived of. They are 
pain, inflammation ; and, if not fortunately cured, the ul- 
timate consequences are hectic fever, and death, from 
caries. 

The symphysis pubis is formed of a fibro-cartilage ; 
passing across from one bone to the other, and so 
strong, as to admit rather of the disruption of the bone, 
than that of its own tissue. The inferior edge of this 
ligament constitutes the crown of the pubic arch ; and as 
it has a triangular shape, it is properly called the trian- 
gular ligament of the pubis. In the centre of the inter- 
pubic ligament is found a small synovial cavity. 

An opinion prevails pretty extensively among the 
common people, that the joints of the pelvis are so con- 
stituted, as to yield during labour, in order to admit of the 
escape of the child, which is thought to be always too 
large for the canal, unless it be previously dilated by this 



12 THE PELVIS. 

supposed method. It is only necessary to study the 
relations of the child's head to the pelvis, in order to 
perceive that no such opening of the symphysis is neces- 
sary in ordinary cases of parturition. But, in examples 
of labour wherein a disproportion does exist, either from 
the excessive size of the child absolutely, or from a mal- 
position bringing incompatible diameters into relation, no 
doubt can be entertained, that these joints maybe forced, 
and often are ; or that the consequences of such strain will 
depend upon its degree, the state of the constitution, and, 
in some measure, on the plan adopted for its treatment. 
Certainly, many of those females who complain of lum- 
bagos and sciaticas supervening upon severe labour, 
should be suspected, at least, of some injury suffered in 
these articulations. 



CHAPTER II 



THE CHILD'S HEAD. 



The study of the form and dimensions of the pelvis, 
derives its chief importance from the relation existing 
between its proportions and those of the child's head. 
This therefore will be the proper place to speak of the 
foetal head, and to show how its form and dimensions 
come to bear upon the measurements which we have 
assigned as the average dimension of the pelvic pas- 
sages. 

The bones of the foetal head are not firmly united ; 
they may even be entirely separated from each other by 
maceration in water ; and, in the living child, they are so 
loosely bound together, that they may be made to move 
by a very moderate degree of pressure. 

The mobility of the cranial bones admits of a length- 
ening or shortening of the several diameters of the skull, 
under the forcible pressure to which it is subjected 
during its transit through the passages ; but we are to 
estimate these diameters as they exist when not under 
pressure, and we find that they present an average, which 
will now be stated. 

The diameters of the foetal head are: 1st, the oblique, 
which extends from the symphysis of the chin to the 
vertex or point of the head, in length five inches ; 2d, the 
longitudinal or horizontal, which extends from the space 
between the eyebrows to the vertex, in length four 
inches ; 3d, the transverse, which passes through the 



14 THE child's head. 

skull from one parietal protuberance to the other, three 
inches and a half; and 4th, the perpendicular, which 
reaches from the top of the skull to its base, also three 
inches and a half. 

The head is of an oval shape, and if held in the hand 
will at once be seen to be largest at its occipital extrem- 
ity, so that if the vertex present, the largest end of the 
head will of course descend first, and its smallest cir- 
cumference, equal to ten and a half inches, will be nearly 
parallel to the successive planes of the canal. Let it now 
be observed that the foramen magnum of the occipital 
bone is on one side of the oval, and that it is there articu- 
lated with the neck ; and it will be seen, that if the vertex 
descends foremost, the chin must be pressed down towards 
the front of the throat, whereas if the face presents first, 
the occiput must be thrown back so as to be pressed 
against the back of the neck or betwixt the shoulders; 
so that if the head advances either with the vertex first, 
or the face first, its smallest diameters or circumferences 
will be in accord or parallelism with those of the mater- 
nal pelvis, that is, its oblique diameter will be parallel or 
nearly so to the axis of the pelvis. Hence we find that a 
child may be born very well either face foremost or vertex 
foremost; and indeed, some of the French writers assert, 
that in face presentations there is very little more, or 
perhaps not more difficulty than in those of the vertex — 
a most important fact if it be true, inasmuch as the face 
presentations have been heretofore regarded as indicative 
of the very serious operation of turning. We have seen 
a child, which at birth weighed eleven pounds avoirdupois, 
born face foremost with very little more effort or pain 
than v/ould have accompanied its birth had it presented 
by the vertex, and that too in a first labour ; we have also 
seen face cases which absolutely required the aid of the 
forceps, and even that of the crotchet, and in which the 
children would probably have been naturally delivered 
had the vertex presented. But we must remit this topic 
to its proper place in this work. 

From the incompleteness of the ossification of the 
foetal cranium, there are left in it certain spaces which are 
not occupied by bone, and these are easily distinguished 



i 



THE child's head. 15 

by their soft or elastic feel under the finger. They are 
called the moulds or openings of the head, and are tech- 
nically denominated the Fontanels. There are two prin- 
cipal fontanels, the anterior and the posterior. The 
former at the anterior and upper angles of the ossa parie- 
talia, and the latter at the posterior and upper angles. 

The student is aware, that in the early stages of the 
fijetal ffrowth, the suture called sadttal, extends from the 
nose backwards to the occipital bone, and tha^the coronal 
crosses the sagittal, from one temporal bone to the other. 
The anterior fontanel, therefore, will have four suture 
lines passing from it; and it is often an inch long and 
lialf an inch in width, so that when touched by the 
finger high up within the pelvis, the mere size of the 
membranous space, as yet unossified, ought to serve as 
a sufficient means of discriminating between it, and the 
posterior or occipital fontanel. But the latter, known 
by its smallness, may be also well known by the cir- 
cumstance that it has only three suture lines running 
out from it; namely, the sagittal, which proceeds for- 
wards, and the two legs of the lambdoidal, which extend 
downwards and backwards ; for the sagittal suture stops 
at the top of the occipital bone, except in a few very rare 
instances in which it is observed to pass downwards, 
dividing the occipital bone into two equal portions, a case 
which might very well mislead an incautious practi- 
tioner. The posterior fontanel is very small, and is 
generally so small, that it can only be known by the 
circumstance of its having but three suture lines pro- 
ceeding from it like radii. As the ossification of the 
bone is more complete here than at the part where the 
anterior fontanel is situated, the practitioner can often 
determine which fontanel he touches by the hardness 
and roughness of the suture edges on which his finger 
rests. 

In many cases, the head, previously to the birth of the 
child, acquires a great degree of firmness. It is proper 
to remark, that in difficult labours, avery firm ossification 
of the bones of the cranium is a cause of increased diffi- 
culty, on account of their inaptitude to yield, and thus 
permit the volume of the cranium to be diminished under 
the pressure. 



CHAPTER III 



THE DEFORMED PELVIS. 



Notwithstanding a wise Providence has so happily- 
constituted the relative dimensions of the fcetalhead, and 
the maternal pelvis, that the parturient female is, in the 
vast majority of cases, enabled to bring forth her offspring 
without any preternatural effort or suffering, it unfortu- 
nately happens that this just proportion does not always 
exist, and that, in consequence of disease, the pelvis 
may be smaller, or the head may be larger, than they 
ought respectively to be. 

Many writers speak of a deformity of the pelvis, which 
consists simply in an excessive amplitude of the whole 
of its canal, and great evils are supposed to result from 
this species of deformity. I question much whether 
deformity is a proper term for a conformation, which 
could only have the effect of rendering the birth of the 
child more facile and rapid ; nevertheless, as several in- 
conveniences are found to arise from such a conforma- 
tion, they shall be briefly mentioned and explained 
before we proceed to treat of deformed pelvis, more pro- 
perly so called. 

At the fifth month of pregnancy the womb has become 
so large that it rises out of the cavity of the pelvis, and 
is then supported upon the top of the pubes, so that the 
woman is from that time relieved from the incommodity 
which she would experience should the lower end of the 
uterus continue to occupy the excavation ; but, if the 



THE DEFORMED PELVIS. 17 

pelvis be possessed of an excessive amplitude, the womb 
does not rise up as it ought to do ; the female continues 
to experience, throughout the uterogestation, the symp- 
toms of a prolapsus of that organ, the lower end of the 
womb sinking down towards the perineal strait, and in- 
commoding both the rectum and bladder by its pressure, 
and producing that uneasy sense of dragging weight, 
and pain about the loins, which are chracteristic marks 
of prolapsus uteri. 

When labour comes on in a woman with a very 
ample pelvis, her throes have the effect of urging the 
whole body of the uterus down towards the perineal 
outlet, and hence, before the mouth of the womb is 
fully dilated, the head of the child, still partially en- 
veloped in the und dated womb, may be pushed through 
the vulva. On the other hand, if the orifice of the womb 
should yield readily, the head, finding little resistance 
from the capacious bones of the pelvis, is liable to be very 
suddenly expelled, and the womb, surprised, as it were, 
by the sudden evacuation of its cavity, falls into a state 
of atony, the consequence of which might be either he- 
morrhage, or inversion of the organ. These are the in- 
conveniences resulting from deformity from excessive 
amplitude. The reader will see that most of them may 
be readily obviated by a careful practitioner, and that 
they possess a greater apparent, than real importance or 
magnitude. Not so with deformity from want of am- 
plitude. 

Inasmuch as the bony frame of one individual may 
differ from that of another, in respect to size and form, 
some being very large and others very small, as the head 
of one woman is smaller than that of another, it is evi- 
dent that the pelvis may be smaller in one than in an- 
other. A woman shall have a pelvis, which, to all ap- 
pearance, is perfectly well formed, all its parts bearing 
a due proportion to each other, whereas, when it comes 
to be measured, it is found to be of an under size. Such 
a female would experience far greater difiiculty in giving 
birth to her child than she would if her pelvis had been 
of a full size, and the difficulty would be just in propor- 
tion to the departure from the average or standard size. 



18 THE DEFORMED PELYIS. 

Such a pelvis will perhaps never be found to give rise 
to insuperable difficulties ; it will only render the labour 
slow and vexatious, and perhaps exhausting-. But the 
truly deformed pelvis, that in which the proportion be- 
tween the several parts is altered or destroyed, is not 
unfrequently met with, giving occasion to the greatest 
embarrassment to the practitioner, and subjecting the mo- 
ther to the most dreadful sufferings, danger, and even 
inevitable death itself. 

This kind of deformity may have taken its rise in 
childhood, or may have been produced after the woman 
had attained to adult age. In the former case it is com- 
monly the result of rickets, in the latter of malacosteon. 

In both these diseases the solid phosphate of the bones 
is absorbed, to such a degree, as to permit them to yield 
to pressure, so that, if the subject be greatly affected 
with the disease, the long bones, as the ossa femoris, 
the tibia, the ossa humeri, &;c. assume an arcuated appear- 
ance, which probably results from the continued action of 
the muscles, tending naturally to bend or curve them. 
Thus, the femur is found to be arched by the perpetual 
action of the strong flexors of the leg, which have this 
advantage over the extensors, in ihis case, viz. that the 
femur is naturally somewhat curved in the same direc- 
tion which the action of the flexors tends to give it. 

If the deprivation of phosphate of lime should extend 
to the bones of the pelvis, in any case of rickets, a change 
in the form of that part will result from the superincum- 
bent weight of the body, both in the act of sitting, and 
standing. If the patient be often or long in a standing 
posture, the whole weight of that part of the individual 
which rests on the vertebral surface of the sacrum, tends 
to crush the sacrum dowjiAvards towards the ossa pubis, 
because the pressure is opposed by the acetabular por- 
tion of the pelvis, resting as it does upon, and resisted 
by the ossa femoris. Under these two opposing forces, 
the thin flattened parts of the ossa ilia, which form the 
top of the sacro-sciatic notches or arches, yield, and 
allow the upper edge of the sacrum, called its promontory, 
to descend towards the pubis, and thus occupy the supe- 
rior strait, more or less completely, according to the 



THE DEFORMED PELVIS. 19 

extent of the diseased softening of the bones. When 
the patient recovers her health, she recovers with a per- 
manent distortion of the pelvis. The new calcareous 
deposit takes place in the bone, already modified in shape, 
and thereby renders the distortion incurable. 

The varieties of form assumed by the pelvis, under 
this strange disease, are very great, yet an attempt has been 
made to arrange all the deformities under certain specific 
characters, for which the reader may consult Madame 
Boivin's Memorial, or Velpeau's Elements. I do not 
clearly perceive the advantage derivable from a learned 
nomenclature of these unfortunate deviations of structure. 
They must ever vary, according to a multitude of contin- 
gencies in the locality, or degree of the malady, so as to 
defy every attempt at classification. 

It sometimes happens, that, instead of the promon- 
tory advancing into the centre of the strait, the pubes 
are found to retreat towards the sacrum ; or, one side of 
the pelvis is exceedingly narrowed ; or, the horizontal 
rami of the pubis approach each other, so as to become 
nearly parallel, and thus jut out, like a tongue, in front. 

In some cases the superior strait is scarcely changed 
at all, while the tuberosities of the ischia approach very 
near to each other, carrying along with them the sides of 
the pubic arch, and thus rendering the outlet of the pel- 
vis wholly impassable for the child, and even for the 
hand of the accoucheur.* 

The sacrum may become excessively curved, its apex 
rising up towards the arch of the pubis, so as to occupy 
part of the perineal strait. 

The efiect of these various modifications of form can 
easily be conceived of by the student, who reflects that 
the child's head is of an ascertained diameter, which 
requires a corresponding magnitude of the bony piissag^s 



* I have seen such a pelvis in the University of Pennsylvania. 
It was the pelvis of a woman who died undehvered, a few years 
ago, in the Philadelphia Alms House, after firmly rejecting the 
relief that was proposed to her, by means of the Caesarian opera- 
tion. To introduce the hand into the region of the upper strait 
is impossible, even in the dried pelvis. 



««H*OMiMkM*<ta|MMfa 



20 



THE defor:\ied pelvis. 



through which it is destined to make its escape from the 
maternal organs. 

In addition to the distortions arising from rickets and 
malacosteon, the female pelvis is liable to be obstructed 
by exostoses, which may become so large as to prevent 
the exercise of the parturient function. ' Thus, Madame 
Boivin gives a drawing of one which grew from the left 
sacro-iliac symphysis ; and Dr Dewees tells of a speci- 
men which sprung from the anterior part of the ileo- 
pectineal line, and occasioned the death of the lady, 
whose womb was ruptured from its pressure on the 
sharp process of diseased bone. 

The spinous processes of the ischia also may receive, 
either originally or adventitiously, an unfavourable in- 
clination inwards, so as to encroach upon the space 
destined for the passage of the head, which is sometimes 
arrested by this spine, or very severely contused during 
its transit over it. 

Many interesting considerations, arising out of a view 
of the deformities of the pelvis, may be very properly 
deferred until we come to speak of those difficult or 
impracticable labours, of which they are the principal 
causes, and along with which thay may be better ex» 
plained. 



I 



CHAPTER IV. 



THE ORGANS OF GENERATION. 



The organs of generation are divided into external 
and internal, the latter term being applied to those which 
are contained within the cavity of the pelvis, and the 
former referring to those that appear upon the external 
surface of the pelvis. 



The extemal sexual organs, in the aggregate, are 
indicated by the word Pudendum ; a word very happily 
selected as a reference to, rather than a direct denomi- 
nation of, a part of the body which the sex, without 
exception even of many barbarous tribes, endeavour 
modestly to conceal. We are told that the first sinful 
indulgence of the human appetites, was succeeded by 
the deepest consciousness of exposure upon this subject, 
and the fig-leaf, which concealed the shame of the first 
woman, is a simple expression or emblem of female 
delicacy. The Venus de Medici is not less expressive 
of female modesty, than of the perfection of the female 
form: its modesty is the key to that inimitable, univer- 
sal and pervading beauty, which places it at the head of 
the ancient works of art, and renders the statue at once 
a truth in morals, and a high compliment to the sex. 

Notwithstanding the aversion of females to every 
allusion to the pathological or obstetric affections of these 



22 THE ORGANS OF GENERATION. 

organs, it is unavoidably incumbent on the practitioner 
to make himself acquainted with their anatomical struc- 
ture, since they are the seats of diseases and accidents, 
and the agents of processes which the practitioner is 
often called upon to superintend ; and it would be the 
grossest injustice to the female patient, to assume the 
conduct of some of her sexual disorders, without a perfect 
preparation for the discharge of duties which, by their 
importance, necessarily take precedence of considera- 
tions that, under other circumstances, it would be both 
wicked and disgusting to pretermit. Let the student of 
midwifery, therefore, experience no sentiment at vari- 
ance with the mens sibi conscia recti, in turning his 
attention to this portion of our subject. 



The surface of the body which is found in front of, 
and just above the symphysis of the pubis, is raised so 
as to present the appearance of a protuberance, which, 
at the period of puberty, is covered abundantly with 
hair, and has received the denomination of Mons Vene- 
ris. The cutis which covers this part is supplied with 
numerous sebaceous follicles, and is ordinarily of a 
darker colour than the general superficies. The size of 
the protuberance varies in different individuals, being 
greatest in those who are fat, and almost disappearing 
in those who are much emaciated. The subcutaneous 
structure is largely supplied with an adipose deposit, 
•contained in cells, connected by so dense a tissue, that 
inflammations and abscesses occurring within it, are 
rendered remarkably painful, as is the case in all such 
affections occurring in unyielding textures. 



A litde below the top of the pubic symphysis com- 
mences the genital fissure, which is most 'commonly 
designated by the term Vulva. The parts which are 
separated by this fissure are called the Labia Pudendi, 
or Labia Mnjora. They are composed of skin, which 



THE ORGANS OF GENERATION. 23 

is divided at the inferior part of the mons, in order to 
admit of this construction, the division extending down- 
wards to the lower extremity of the vulva, where it ter- 
minates in the inferior commissure of the vulva, or an- 
terior edge of the perineum. The labia, which externally 
consist of cutis, in all respects similar to that of the mons, 
and like it covered with hair, are internally lined with 
an epithelion, that serves to protect the mucous surface 
beneath. The basis of their structure is a rather loose 
cellular tela, supplied less abundantly than the part above 
with adipose cells, and therefore liable, during inflamma- 
tion, to a great degree of swelling. The labia also, 
since they serve as the outer limits of the vulva, are 
liable to a great degree of elongation, or distension, 
during the transit of the child in parturition. This dis- 
tension is so great that it equals a circle of about ten 
inches in circumference. As the superior commissure 
of the vulva is found at least one inch above the bottom 
of the symphysis pubis, and the festal head passes out 
between the top of the pubic arch and the inferior com- 
missure of the vulva, the student will appreciate the very 
great extensibility of the labia majora ; nor w^ill he ex- 
perience any surprise upon being informed that a very 
great degree of force is required to overcome their resist- 
ance ; that much time is often consumed for that end ; 
or that the labia are occasionally ruptured before they 
become sufficiently extended to admit of the escape of 
the head. I have seen one instance in which the left 
labium was broken transversely during the transit of the 
head in a first labour. No evil consequences ensued in 
that instance, the wound uniting by the first intention. 

AVhen the labia are put excessively upon the stretch, 
it occasionally happens that some of the blood vessels, 
with which they are abundantly supplied internally, give 
way, and a quantity of blood is poured out into the cel- 
lular tissue within. The extravasation may amount to 
only a teaspoonful, or may equal half a pound. Of course, 
in such a case, the organ must be greatly swollen, and 
of a dark cok)ur, causing very sesrere pain, or sloughing 
of the part. The swelling is generally discovered soon 
after the conclusion of the labour. The blood may 



24 THE ORGANS OF GENERATION. 

be removed by making a free incision, to be practised 
upon the internal surface of the labium, which indeed 
will be most easy to come at, because, in extensive 
swellings of this part, there is always eversion of the 
labium, and not inversion, in consequence of the greater 
density of the cutis. The same thing is observed in 
swellings of tlie lips, which seem to be then everted ; so 
also in swellings of the eyelids, where some degree of 
ectropium is a common result of great distension. 

Pregnant women are frequently afflicted with oedema 
of the lower extremities. The swelling, in some ex- 
amples, extends up along the thighs, and the watery 
infiltration causes a very great swelling of the labia, as 
soon as the infiltration reaches them. I have seen a 
case in which, notwithstanding that I punctured the 
labia repeatedly, antecedently to the approach of labour, 
so as to permit the serum to escape, the labia and peri- 
neum were so swollen and hard, as to produce the high- 
est degree of embarrassment during the parmrient efforts. 
Where the swelling is great, several punctures with a 
lancet should be made, towards the close of pregnancy, 
in order to permit the fluid to escape. A lesser degree 
of tumefaction does not demand so unpleasant a remedy, 
the water of the cellular tissue being pressed out by the 
advancing head, and dispersed into other portions of the 
cellular texture in the vicinity of the vulva. 

The labia, occasionally, are the seats of abscesses that 
are excessively painful. They point towards the inner 
surface, for the most part. They suppurate rapidly, and 
should be opened as soon as a deposit of pus can be 
ascertained to exist. Few cases will probably be found in 
which the medical attendant shall be able to discuss such 
inflammation, since their location deters the female from 
calling for his aid, until intolerable pain or inconvenience 
compel her to do so ; and at such a stage, suppuration 
will, for the most part, be found inevitable. 

Whenever it is deemed practicable to eff'ect a resolu- 
tion of such inflammation, it ought to be attempted ; 
since we know not what change of structure may take 
place, in consequence of abscesses in the labia. What- 
ever causes tend to afiect the labia with permanent alter- 



THE ORGANS OF GENERATION. 25 

ations of their form or density, are to be always carefully 
obviated, since the part they perform in labour is highly 
important. A bleeding from the arm, followed by leeches 
to the part, and fomentations with decoction of linseed, 
saturnine applications, &:c., will be proper, upon the 
institution of an attempt to discuss an abscess in the 
labium. 

In young children it not unfrequently happens that the 
inner face of the labia pudendi becomes irritated, which 
results in adhesive inflammation, uniting the surfaces 
that are in mutual contact. The frequent evacuation of 
the bladder, of course, will always prevent a union of 
the whole extent of the labia. 

In all the cases of this kind that have fallen under my 
notice, I have found it sufficient to separate the united 
surfaces by drawing them apart with the fore and middle 
finger of the left hand, while, with the end of a probe, 
drawn down directly upon the line of union, the adhe- 
sions are easily destroyed, and that without occasioning 
the least bleeding. The scalpel has never been required. 
I have no doubt, however, that a case may occur, in 
which, by long neglect, the union should acquire so 
great a degree of solidity as to yield only to the knife. 

When the labia shall have been separated, in these 
instances of cohesion, they should be carefully kept from 
coming into contact, by a pledget covered with cerate, 
as the adhesive tendency is renewed by the very violence 
which is required to obviate the consequences of a pre- 
ceding irritation. 

The appearances presented by the labia in virgins, are 
diflTerent from those occurring in females who have borne 
children. In the latter they present a somewhat shrivelled 
or collapsed appearance, except in fat persons ; and the 
inner surface, which in virgins is of a rose tint, becomes 
bluish in the aged, or those who have had children. 
The inferior commissure, also, is lower down in wo- 
men who have borne children ; whereas, in the virgin 
state, the lower commissure crosses the pubis almost as 
high up as the top of the triangular ligament. This is 
found to occur in most young females, examined early, 
in a first labour. 



26 THE ORGANS OF GENERATION. 



The Nymphae are also called labia — ^labia minora, 
labia interna. They differ from the greater labia in 
that they consist of a duplicature of the mucous mem- 
brane, covered with a strong epithelion, and contain- 
ing an erectile tissue ; whereas the greater labia have a 
basis of adipose texture, possessing no erectile struc- 
ture. In young persons the nymphae are wholly con- 
cealed within the genital fissure ; but in those who are 
somewhat advanced in age, and who have borne chil- 
dren, one of them may be commonly observed to pro- 
trude beyond the vulva, a circumstance which depends 
much more upon a change of its proper structure, than 
upon the shrinking of the labia consequent upon advanc- 
ing age and repeated parturition, as has been already 
mentioned. The top of the nymphae is but little below 
the superior commissure of the vulva, and each-nympha 
descends obliquely outwards, terminating rather more 
than half way down the labium of each side. This 
arrangement gives it the appearance of a pointed arch. 

The colour of the nymphae, in young persons, is a 
lively red, and their surface is not corrugated ; whereas 
in women who have borne children, they assume a 
darker hue, and are sometimes very muah corrugated, 
not unfrequently presenting a lobulated appearance. 
Haller informs us that hairs are occasionally found to 
grow upon them. They are abundantly supplied with 
a peculiar kind of sebaceous matter, which, in uncleanly 
individuals, accumulates in considerable quantities, giving 
rise to a disgusting foetor. 

It is useless to inquire into the motives for bestowing 
upon this organ a title which appertains to the divinities 
that preside over fountains. It is at least certain that 
these bodies exercise no influence over the sources or 
direction of the urine. It is asserted that they subserve 
a very important end, to wit, the supply of an additional 
material for the distensions which these parts undergo 
in the last moments of labour, thus diminishing the risk 
of rupture of the external parts of generation. I have, 



THE ORGANS OF GENERATION. 27 

however, repeatedly ascertained, that at the instant of 
the extremest distension of the vulva, the nymphae are 
not effaced, but can be distinctly felt, like a firm ridge, 
little less elevated or marked than in the most entire 
repose of the organs. It is easy to verify this fact in 
any case of labour. 

There is high authority for the assertion that they are 
the subjects of erection under the excitements of the 
sexual passion, and possibly they may concur, therefore, 
in the production of the orgasm which seems essential 
to conception. It is proper to say, however, that the 
uses of the nymphae are unknown. They do not exist 
in any other species of mammalia, agreeably to the de- 
claration of Mr Lawrence, in his notes to Blumenbach's 
Comparative Anatomy. 

Notwithstanding that the fold of the nymphae is not 
effaced or flattened out in labour, it sometimes happens, 
that while contingently elongated by the extension of the 
labia, they suffer lacerations. Like all other living tissues, 
they are obnoxious to inflammatory diseases, which are 
often extremely painful. The treatment of abscesses of 
these parts is conducted upon the same principles and 
indications as occur in those of the labia majora. 

In those individuals in whom they protrude beyond 
the external surface of the vulva, excoriations of them 
are occasionally met with. Where such excoriations are 
rebellious under treatment, it is best to remove the pro- 
truding portion by the scalpel or scissors. This opera- 
tion may be safely resorted to, since it is a prevalent 
custom among many tribes of Arabs and Moors, and also 
the Coptic inhabitants of Egypt, to apply the rite of cir- 
cumcision, or rather excision, to the young female. 

It can not be needful, in a work so limited as this, to 
to enter into investigations concerning the so much 
talked of tablier des Hottentotes. For an ample account 
of the subject I refer the curious student to Mr Law- 
rence's Phys. and Zool. of Man, page 420, where a 
very sufficient number of authorities maybe found. M. 
Merat's remarks on the same subject may also be ex- 
amined, sub voce, in the Diet, des Sc. Med. 



28 THE ORGANS OF GENERATION. 



The tip of the Clitoris juts out under the summit of 
the pointed arch formed by the nymphae. The clitoris 
possesses very considerable analogy to the male penis : 
it consists of two corpora cavernosa, possessing two 
crura, which, like the crura of the male penis, are at- 
tached to the ossa pubis ; and the analogy may be further 
prosecuted, by attending to the manner in which the 
deep crescentic fold of the upper part of the nymphse 
surrounds the apex of this organ. This fold is called the 
preputium clitoridis. The clitoris differs from the male 
penis in that it possesses no corpus spongiosum, and of 
course it can have no real glans, or urethral canal. It is 
erectile, and is endowed with the most intense erotic sen- 
sibility. The uses of the organ are probably to be sought 
in this peculiar endowment. Its universal occurrence in 
the mammalia bespeaks its importance. We are assured 
by Blumenbach, in his Comparative Anatomy, that the 
only animal belonging to this class in which it is wanting, 
is the Ornithorynchus of New Holland, and that animal is 
truly denominated paradoxus. 

The clitoris is the subject, in some individuals, of so 
great a degree of hypertrophia, that it comes to bear a 
marked resemblance to the male organ. Such affections, 
doubtless, are the causes of a prevalent vulgar belief in 
in the existence of hermaphrodites. The cases of 
monoecious vegetables and of some zoophytes, as the 
earth worm and other inferior creations, may be cited as 
examples of the double sex in an individual constitution. 
The Indian corn, for example, fecundates by its male 
organ its own female germ. But notwithstanding that 
monoecious plants, and some of the lower orders of the 
animal kingdom, contain within their bodies the organs 
of a double sex, we are not authorised to admit that a 
similar condition can occur in beings of a highly complex 
organization, where an entire individuality of the male 
and female are and must be indispensable. The prayer 
of Salmacis, that her lover's body and her own might be 
united into a single one, although granted by the mytho- 



THE ORGANS OF GENERATION. 29 

logical divinities, leaves the sexual individuality both of 
Salmacis and Hermaphroditus undestroyed ; and so must 
it always be both in nature and imagination. 

Wherever suspicions are entertained of the existence 
of an hermaphrodite, it will probably be found that an 
enlarged clitoris, or a bifid scrotum, presenting the ap- 
pearance of labia pudendi, have given rise to the sus- 
picion. 



Just on a line with the top of the pubic arch, is a small 
bulbous projection, which encloses the orifice of the 
urethra : the triangular space included betwixt this 
bulb, the nymphae and clitoris, is called the Vestibulum. 
It is important to understand its position, because it is 
always referred to in introducing the catheter, which is 
very easily performed with a correct knowledge of this 
part, and very difficult of execution in the absence of 
such knowledge. The lower part of the vestibulum is 
divided by a raised line or raphe, which can be readily 
felt with the point of the finger, and which leads directly 
to the orifice of the urethra, to which it should serve as 
a director in the operation above mentioned. 



The female Urethra is from an inch and a half to two 
inches in length. It turns upwards and backwards 
directly under the triangular ligament of the pubis. In 
introducing the catheter, the point of the tube should 
be directed perpendicularly to the surface of the vestibu- 
lum, and introduced within the orifice of the urethra, 
and then, by depressing the handle, the point will turn 
upwards behind the bone towards the orifice of the 
bladder. Notwithstanding that the female urethra is so 
short, it often happens that the bladder, when very much 
distended with urine, and particularly during labour, is 
carried very high up, so that the urethra is elongated. I 
have been several times obliged to introduce the catheter 
fully four inches, before it would enter the bladder of 



30 THE ORGANS OF GENERATION. 

urine. The urethra is also very much elongated in some 
cases of retroversion of the womb. 

On account of the situation of the urethra, it is some- 
times subjected to so severe a degree of pressure by the 
foetal head, that it sloughs before or after delivery, and 
gives rise to the distressing symptoms of urethro-vaginal 
fistula. It is also subject to contusion and laceration in 
some of the forceps or crotchet operations ; accidents 
that cannot be too carefully guarded against by every 
humane or considerate practitioner, as entailing upon 
the patient the most distressing stillicidium of urine. 

Not very long since, in examining a female vi^ho com- 
plained of a constant flowing of urine, I passed three 
fingers, side by side, into what had once been the cavity 
of the bladder, but was now a blind sac, connected with 
the anterior part of the vagina. She informed me that 
she had been delivered with forceps, some weeks pre- 
viously to my visit, after a lingering labour. I have 
very lately seen a young female with a fistula which 
seems to enter the vagina at its very top, where in 
contact with the neck of the womb. It is connected 
with the upper part of the urethra, and gives issue to 
a perpetual flow of urine. 

The treatment of urinary fistulr. is very difiicult. An 
essential condition in the cure, is the prevention of the 
stillicidium during the curative processes. Hence, a 
catheter of convenient length should be worn in order 
to permit the urine to escape by the course of the ure- 
thra, and not through the fistulous opening, which thus 
is permitted to contract, and ultimately to become closed. 
Where the opening is very small and callous, it is possi- 
ble to conduct to it an actual cautery, guarded by a 
canula of proper dimensions. So severe a remedy, how- 
ever, could only be resorted to after a patient trial of the 
eflicacy of the catheter used as above mentioned. 



The Hymen is a fold of the mucous membrane of the 
genital surface. It is a crescent, with the cornua directed 
forwards. It is situated just within the entrance of the 



THE ORGANS OF GENERATION. 31 

vagina ; and is so thin and delicate as to yield to a slight 
force ; whence it is often wanting in adult persons, having 
probably been ruptured during infancy or childhood. 
Certainly there are many very young subjects met with in 
the anatomical rooms, in which no trace of it is to be dis- 
covered. The fold of mucous membrane of which it is 
composed, is broad in some, and very narrow in others. 
I am well convinced that I have, in many instances, met 
with the unruptured hymen during my obstetric prac- 
tice. I may venture to assert, that whoever attends a 
great many women in their first labour, will have occa- 
sion to observe the existence of a very narrow hymen in 
many such persons. I make this statement, not unaware 
that I may be charged with having mistaken the four- 
chette for the organ in question. I think, however, that 
my opportunities in midwifery practice for acquiring 
experience, have been so sufficiently ample, as to war- 
rant me against the commission of so gross an error. 

In some individuals, the hymen is not crescentic, but 
circular, with an opening in the centre, or in some other 
part of its plane ; and a few examples are met with in 
which the hymen is imperforate. 

Instances are also recorded of such firmness in the 
tissue, that incisions have been required in order to 
allow of the delivery of the foetus, which was prevented 
from being delivered by the resistance of the hymen. 

The foregoing should serve to convince the student, 
that as a test of virginity, this organ cannot be relied on, 
since it is often wholly wanting ; so slightly developed 
as to oppose no resistance in coitu ; and, even in labour, 
to require the aid of the surgeon for its destruction. 

The barbarous practices of some of the African na- 
tions, and the distressing suspicions and doubts which 
sometimes are connected with the vulgar errors on this 
subject, ought, if possible, to be exploded. It appears 
to me to be the duty of the physician to speak in positive 
terms, and whenever suitable occasions offer, to repro- 
bate so useless and often injurious a dogma. 



32 THE ORGANS OF GENERATION. 

A space that exists between the Fourchette, which is 
the inferior commissure of the labia, and the hymen, is 
called the Fossa navicularis. The fourchette is a pretty 
firm fold of the tissues, serving to unite the lower extre- 
mities of the vulva. It is said to be generally ruptured in 
a first labour, which I do not admit. It is doubtless often 
broken, and no evil consequences commonly ensue. 



Although the term Perineum should in strictness apply 
to the whole of the space between the point of the coccyx 
and the lower end of the genital fissure, it is com- 
monly used in a more restricted sense, and indicates that 
space which exists between the lower end of the vulva 
and the anus. It is from an inch, to an inch and 
a half in length. It is covered externally and below 
with skin. It is limited above by the vagina, and pos- 
teriorly by the rectum ; for, as the vagina and rectum 
are united by what is called the recto-vaginal septum, 
it is evident that the triangular space existing betwixt 
this septum, the fourchette and the anus, must constitute 
the perineum, using the word in its common acceptation. 

It is very thick in some women, and feels extremely 
hard and resisting; in others it is very thin, soft, and 
easily dilated. Upon its rigidity or its extensibility de- 
pends the amount of time which will be required for its 
dilatation by the foetal head, or other presenting part. 

I have already mentioned that the anterior edge of the 
perineum is, in many women, but little below the top of the 
pubic arch, and that the vulva is not distended until after 
the perineum has been pushed outwards and distended. 
It does sometimes happen that more than one half of the 
foetal head escapes from the lower strait, carrying out the 
perineum along with it, while the vulva is only opened 
enough to let the apex of the head emerge a very little. 
When distended in this way, the perineum is perhaps 
not thicker than the scalp, or even less, and covers the 
head like a cap, and instead of being from an inch to an 
inch and a half long, measures between three and four 



THE ORGANS OF GENERATION. 33 

inches. This great extension is sometimes kept up for 
a considerable length of time. 

The time necessary for the complete expansion of the 
perineum is very different in labours. 1 have sat six 
hours by the bed after the head had begun to distend 
this part, and witnessed repeated efforts of the womb to 
overcome the resistance, the head being always pushed 
back into the excavation by the elasticity of the perineum, 
until at last, some long and powerful pain has forced 
it through the birth. It is very important, in making a 
prognosis, to have a very careful reference to the state 
of the perineum, as it, alone, often furnishes greater re- 
sistance, and consequent delay, than the os uteri, the 
straits, and the vagina together. 

There are not a few cases in which it wholly refuses 
to dilate, and then the child is forced downwards at the 
expense of the tissue, which bursts or is rent asunder, 
allowing of the immediate egress of the head. 

This laceration of the perineum generally takes place 
when the vulva is largely distended, the rupture com- 
mencing near the fourchette, and extending back as far 
as the anus, or even into the rectum. In other instances 
the child has been expelled through a laceration of the 
perineum proper, not including the fourchette or any 
part of the vulva, the perforation being made betwixt 
the anus and vulva. 

When such accidents happen without involving the 
bowel or its sphincter muscle, no very bad consequences 
are apt to ensue, the parts readily uniting by the conti- 
nued and close contact of the surfaces. 

Should very hard and extensive cicatrices be formed 
in consequence of such lacerations, the vagina and peri- 
neum may be rendered less fitted for the distensions of 
a subsequent labour, in which great care ought to be 
taken to obviate the repetition of so very untoward an 
accident. 

Lacerations do not always commence at the fourchette. 
I have already mentioned a case in which the lower 
third of the right labium was broken off, and an irregu- 
lar lacerated wound extended from that point towards the 
perineum. The accident cannot be always avoided^ 



34 THE ORGAN'S OF GENERATION'. 

even by the greatest care and skill. Whenever the 
power that urges the child forth is very great, there is 
danger the infant may be expelled before the perineum 
and vulva have sufficient lime to dilate : they are there- 
fore, apt to be ruptured. Lacerations sometimes take place 
in forceps operations ; probably from want of patience in 
waiting for the dilatation of the parts ; time not being 
allowed for the yielding of the textures. It is the duty 
of the accoucheur to see that the parts shall have time to 
relax and dilate before the head is permitted to emerge ; 
an end Avhich he can generally compass by aiding the 
perineum ; making pressure against it so far as he may 
dare, and thus, while the head is kept from advancing, 
permitting the tissues to acquire the proper temper or 
disposition to yield. This, however, will be more 
apropos when we come to treat of the management of 
labour. 



The Vagina is a membranous tube that connects the 
external with the internal organs of generation. Its 
length varies in different adult persons, being commonly 
longer in virgins than in women who have borne chil- 
dren recently, and especially in such as have given birth 
to a numerous offspring. It is also longer in pregnant 
women about the fourth or fifth month, in consequence 
of the rising upwards of the gravid uterus, which then 
rests on the brim of the pelvis. Its upper and posterior 
part is attached to the rectum by the recto-vaginal sep- 
tum, and it is united to the urethra by the vesico-vagi- 
nal septum ; near its lower end it is provided with a 
sphincter muscle that serves to close it with more or 
less force. 

Occupying the middle of the pelvis, M'here the trans- 
verse diameter is more than four inches long, the sides 
of the vagina, when distended so as to receive the foetal 
head, may be carried laterally as far as the planes of the 
ischia. A great distending force is often wanting for this 
purpose, and the practitioner is detained for hours in 
order to obtain the requisite dilatation of the vagina. Such 




34 



THE ORGANS OF GENERATION. 35 

resistance depends upon the unyielding nature of its own 
proper tissue, and not upon any opposition from the sur- 
rounding textures : there is nothing betwixt it and the 
ischia, except a very loose cellular tela, comprehended 
betwixt the folds of the ligamenta lata. 

The lower end of the womb is attached to the upper 
extremity of the vagina. If the vagina become shortened 
and its two extremities approach each other, the womb 
sinks lower down into the pelvis than its natural level. 
If the vagina be subsequently elongated by any means, 
the womb is carried upwards again. A prolapsion of the 
womb is essentially a shortening of the vagina, and the 
cure of such prolapsion is to be effected by restoring to 
this canal its proper longitudinal dimension. 

The internal lining of the vagina is a mucous mem- 
brane, abundantly furnished with mucous follicles, whose 
secretions lubricate the parts in health, and particularly 
during labour, when their presence is of the greatest con- 
sequence. The parts when deprived of it, by frequent 
examinations, become dry and inflamed, which prevents 
their yielding to the distending forces, whereby the 
patient suffers protracted distress that might be easily 
avoided by abstaining from the touch, and thus preserv- 
ing the humid and soft condition of the organ. Too 
frequent touching not only removes the lubrication, but 
irritates the mucous membrane : it is greatly to be de- 
precated, as not only useless but injurious, as well as 
indelicate. A woman in labour should be examined as 
seldom as possible. 

There seems to be a dissidence in the opinions of 
authors relative to the structure of the vagina, particularly 
that of its tunica propria, which is either a real fibrous tis- 
sue, or a mere condensed laminated cellular membrane. 
It is surely not areolar, and possesses no other contrac- 
tility than that which is called elastic, and which i 
common to the whole of the cellular structure. It closes 
speedily after the passage of a child, even one of a very 
large size. In some instances, where the child's head 
has lingered long in the vagina, an hour or more elapses 
before its calibre becomes much contracted. For some 
hours after the birth of a child, the introduction of the 



36 THE ORGANS OF GENERATION. 

hand into the vagina may be effected with the use of 
very little force. The vagina is subject to eversion, or 
to complete inversion, where there is procidentia or 
inversio uteri. Of course, such accidents can never 
occur, nor can any tendency to them take place, without 
deranging both the bladder and rectum in consequence 
of their textural connexion with this organ. 



The Uterus is attached to the upper end of the vagina. 
It is a pear-shaped body, compressed from front to rear, 
and varies from two and a half, to three inches in length, 
being larger in women who have borne children, than 
in those who have never been impregnated. It is 
divided into fundus, body, and neck ; the fundus being 
the uppermost, and the neck the lowermost part of the 
organ. The vagina is united to the womb in such a way 
as to permit its neck to project a short distance into the 
canal ; in this regard also there is great variety, some wo- 
men having almost half an inch of the cervix uteri hanging 
down in the vagina, while in others the connexion seems 
to exist almost at the lower end of the cervix. See the 
engraving. 

As the vagina is a curved canal, which proceeds back- 
wards from the vulva, and upwards towards the rectum, 
it happens that the womb lies rather nearer to the sacrum 
than to the pubis. The womb is so situated that its long 
diameter is parallel to the axis of the superior strait, 
while the vagina is nearly parallel to that of the infe- 
rior strait : hence, at their junction, they make an obtuse 
angle, any derivation from which implies a displacement 
of the womb. 

The breadth of the womb is about one inch and a half, 
its thickness about one inch. 

Suppose half an inch of the cervix uteri to project into 
the upper part of the vagina; then, if the whole length 
be three inches, we shall have two and a half inches of 
the womb above the upper end of that canal. Such be- 
ing the case, the womb would fall over to the right or left 
side of the pelvis, were it not restrained or stayed by 




36 



THE ORGANS OF GENERATION. 37 

what are called its broad ligaments, which, passing from 
its sides towards the sides of the pelvis, keep it steady 
or prevent its assuming an oblique attitude ; it would 
also fall backwards towards the sacrum, and often be- 
come lodged or wedged under the promontory of that 
bone, were it not restrained from moving in that direc- 
tion both by its round ligaments and by its connections 
with the bladder. It cannot fall forwards, for it is sus- 
tained by the bas-fond of the bladder, which, by filling 
with urine, must and would always push it backwards 
again. 

The substance of which the womb is composed has 
not been fully understood. In the unimpregnated state, 
it is dense and gristly to the feel, and cuts very hard ; the 
cut surface being of a faint pinkish hue, and of a fibrous 
appearance ; but those fibres are disposed without any 
apparent regularity or order. It is supplied with blood 
vessels and nerves, which are very small during the 
unimpregnated state ; but the same vessels in the gravid 
womb acquire an enormous size, and are exceedingly 
numerous and tortuous, so that, in fact, the ovum at full 
term, appears to be contained in a vast net-work, or rete 
vasculosum, united together by a quantity of muscular 
fibres. The womb, at the full term, is an exceedingly 
sanguine organ, being furnished with torrents of blood 
from the uterine and spermatic arteries, the former reach- 
ing it from below, and the latter from above, with free 
inosculation of the several channels of circulation. 

Various attempts have been made to demonstrate the 
muscular fibres of the womb, and they have been divided 
into layers and planes and fasciculi, for that purpose ; 
but the very fact of such diff'erence of opinion is proof 
enough that the arrangement of them is not yet clearly 
known. If it were known and demonstrable, there would 
no longer exist any dissidence concerning it, since what- 
ever is clearly demonstrable ceases to be a subject of 
dispute or doubt. This much, at least, is well known ; 
viz. that the contractile fibres of the womb are capable 
of acting partially, or so as to change the form of one 
part of the organ while another part of it acts with less 
intensity, or not at all. Thus, it occasionally happens 

D 



38 THE ORGANS OF GENERATION. 

that we find the uterus, after delivery, contracted in its 
middle, as if a string had been passed and drawn tightly 
round it, causing it to assume the shape of the hour- 
glass. This state is familiarly denominated an hour- 
glass conti-action : again, we not unfrequently find the 
whole organ elongated, and almost of a cylindrical form ; 
its fundus being raised high upwards towards the epigas- 
trium, while the rest of it is narrow or slender like an in- 
testine. I feel assured ttiat I have sometimes found it, after 
delivery, full nine or ten inches in length, and not more 
than four inches in transverse diameter, estimated by 
feeling it through the relaxed integuments of the abdo- 
men. These circumstances prove that the uterine fibres 
which affect the transverse diameter of the organ may 
act with force, while those which affect its longitudinal 
diameter are either in a state of repose or of very slight 
action ; which leads us, as I think, to the inference, that 
the longitudinal and horizontal fibres are separate and 
independent organs, or parts, of the uterine structure. 

If this be a just view of the case, it will serve for the 
explanation of occurrences in labour that would other- 
wise embarrass us not a little : for example, we find the 
woman in travail sometimes suffering under the most 
intense pains, and making the greatest eff'orts without 
the smallest profit; and that too where we know cer- 
tainly, that the pelvis is of the amplest dimensions. 
What can be the cause that the child does not advance 
under such vigorous eff'orts ? We find that the head is 
positively stationary ; notwithstanding the healthiest pel- 
vis conformation, and a sufficient dilatation of the uterus, 
and violent labour pains. We are at once satisfied and 
relieved of anxious doubts, when we reflect that the 
horizontal or transverse fibres are acting, and the longi- 
tudinal or perpendicular fibres are inert. There is a 
failure of co-ordination in the movements, and our duty 
w^ill be clearly seen to consist in endeavours to restore 
the symmetry of contractile effort. 

As this circumstance generally results from an excess 
of local or constitutional irritation, the former occasioned 
by tedious or violent labour, officious intermeddling, or 
the direct stimulation of ergotism ; and the latter by a 



c 



THE ORGANS OF GENERATION. 39 

too susceptible nervous system, repletion, mental emo- 
tions, or vain efforts of labour long continued : it appears 
that, in the former case, we ought to resort to the tran- 
quillizing influences of laudanum clysters, cool air and 
drinks, and abstinence from impertinent handlings ; 
whereas in the latter we may apply to the lancet, to a 
Dover's powder, to portions of morphia, or the black 
drop, or opium, after evacuations have been procured 
from the bowels by emollient and laxative injections ; and 
tliat we ought to give orders for a full and free ventila- 
tion, and the use of suitable drinks. 

But if it does sometimes happen that the movement of 
the horizontal fibres is inordinate, or in excess, it fortu- 
nately happens in the vast majority of cases that the 
powers of the longitudinal fibres are the greatest. The 
ovum being contained entirely within the uterus, it ap- 
pears that it can only be expelled by the fundus approach- 
ing the OS uteri; or, in other words, by the shortening 
of the womb, that results from the contraction of its long 
fibres. Let us remember that the womb is attached to 
the upper end of the vagina, and that the ovum, in pass- 
ing out from the uterus, must necessarily traverse that 
canal. It will then appear that the first contraction of 
the longitudinal fibres will tend to pull the circle of the 
OS uteri open at the same time that the point of the ovum 
is insinuated into the enlarging orifice. This opening 
or dilatation of the orifice does not take place without 
resistance, which is chiefly perceptible however in the 
early stages; for we find that while the fundus and body 
of the womb are vigorously condensed during a pain, 
the cervix also is strongly contracted, but less and less 
vigorously, as the dilatation becomes more considerable ; 
so that, indeed, it is not rare to perceive the whole circle 
of the cervix yield readily, and as if without opposition, 
to the greater power of the longitudinal fibres. I have 
known the whole dilatation to take place during a natu- 
ral sleep. 

Some women require only a few pains to complete 
the dilatation, whereas others suffer hundreds of pains 
during several successive days, before the circular fibres 



40 THE ORGANS OF GENERATION. 

are conquered by the protracted efforts of their antago- 
nists. 

It requires a considerable experience and trained habits 
of observation to enable a practitioner to prognosticate 
the moment of delivery, making up his judgment from 
the intensity of the pains of expulsion, as compared 
with those of opposition or retention. It is certain that 
no man, be his experience ever so great, or his discri- 
mination ever so acute, can with absolute certainty cal- 
culate upon the moment when any given labour shall be 
brought to a conclusion, since no one can absolutely 
predict what shall be the exact degree of intensity of any 
muscular force, which, as it is a vital operation, so it is 
dependent on causes beyond our knowledge or perfect 
control. Young and inexperienced practitioners ought, 
therefore, to be very slow in announcing their prognos- 
tic of labour. 

I have remarked, that as the longitudinal fibres pull 
the OS uteri open, the apex of the ovum is inserted into 
the opening ; with each succeeding pain additional por- 
tions of the ovum pass into the os uteri, and through it, 
until at last the fundus having approached very near the 
cervix, the whole of the ovum becomes excluded from 
the uterine cavity, after which the same longitudinal 
and horizontal fibres, meeting with no further conside- 
rable resistance, act in concert, and thereby reduce the 
womb down to a very small size. It returns but slowly 
to the non gravid condition. From fifteen to thirty days 
are required to effect this reduction. Let it be remem- 
bered that the womb is capable of contracting equally 
upon an ovum at term, and upon an abortion of three 
weeks. 



The Fallopian Tubes are membranous canals, designed 
to convey the fecundated ovule or germ from the ova- 
rium into the womb. They spring from the latter body 
at its upper angles, one from each angle. The other 
extremity of the Fallopian tube, called fimbria, or morsus 
diaboli, lies loose in the cavity of the pelvis, while in a 



THE ORGANS OF GENERATION. 41 

relaxed state, but when excited by the venereal orgasm 
it becomes erected, and is then directed towards the 
ovarium, the surface of which (in inferior animals) it 
has been seen to grasp tenaciously, for a period of 
time not yet determined. A communication is in this 
way established from the ovary to the womb, through 
the tube, and the fecundated germ passes, by some unex- 
plained mechanism of vital action, from its nidus in the 
ovary to the uterine cavity, in which its subsequent 
growth is to take place, until the birth of the child. 



The Ovaria are two small compressed oval bodies, 
one of which is found on each side of the womb, attached 
to its angles by a footstalk called the ligament of the 
ovary. Each ovary lies behind the Fallopian tube, and 
like it is inclosed betwixt the folds of the peritoneum, as 
it passes from the sides of the uterus in its progress 
towards the lateral parts of the pelvis, under the title of 
the broad ligaments. The peritoneum gives to the 
ovarium its outer coat, which invests its peculiar coat or 
capsule, inside of w^hich is contained a condensed cellu- 
lar tissue, enclosing, as in a gangue or matrix, several 
small translucent globules. These globules are the ger- 
mina or rudiments of embryos. Some of them are very 
near the superficies of the ovary, and others are buried deep 
within its texture. When fecundated, these ovules, called 
also Graafian vesicles, are removed from the ovary by 
unknown processes ; and after passing through the canal 
of one of the Fallopian tubes, are deposited in the cavity 
of the womb, in order there to undergo the changes that 
are described under the head of Pregnancy. When a 
Graafian vesicle leaves the ovarium, there remains in 
that body a yellowish red spot, which, from its colour, 
has received the appellation of corpus luteum. In pro- 
cess of time the corpus luteum disappears, and a cicatri- 
cula only remains to indicate the original seat of the 
unfecundated ovule. 



CHAPTER V. 



MENSTRUATION. 



The Menses is a discharge which is peculiar to the 
human female ; and if any analogies with it have been 
discovered in other orders of the mammalia, they are so 
faint and distant, that it is now conceded, on all hands, 
to belong only to women. It consists of a fluid resem- 
bling blood, and by some writers supposed to be blood, 
which is discharged at certain regular periods from the 
genital organs. Its first appearance is observed, in this 
climate, at the age of fourteen or fifteen years, and it 
ceases to recur from about the forty-fifth year of the 
individual's age. Those who are regular menstruate 
every twenty-eight days, or thirteen times in a year ; 
so that a woman who should continue to be regular 
from the time of the first eruption of the menses in her 
fifteenth, until its cessation in her forty-fifth year, would 
have near four hundred repetitions of the function. 

Each catamenial period continues from three to five 
days ; so that the subject is not free from it more than 
from twenty-two to twenty-five days at a time ; and there 
are many examples to be met with in which the period 
of its duration is not less than seven or eight days for 
each menstruation. 

It is generally supposed that five or six ounces of fluid 
escape on each of these occasions, but there is a very 
great difference as to the quantity yielded by different 
women, each one having a rate of her own, from which 



MENSTRUATION. 43 

she rarely varies, and it might be said, never, unless 
some circumstance may have interfered with her tiealth. 
Deviations from the customary amount, either by excess 
or deficiency, are accompanied or followed by conse- 
quences which are more or less severe ; the excess pro- 
ducing lassitude, loss of appetite, paleness and debility ; 
while any deficiency as to the quantity is often accom- 
panied or succeeded by vertigo, headach, pam in the 
loins, and a sense of weight or distress in the pelvic 
region, the phenomena being also, in many cases, accom- 
panied by fever. The physician, therefore, who should 
be consulted ^vith regard to any fault in the menstrual 
office, would overlook the most important considerations, 
should he fail to make himself acquainted with the con- 
stitutional habits of his patient, as to the quantity and 
periods of her catamenia. 

In health the menses return with surprising regularity : 
a great majority of Avomen expect it with the utmost 
confidence for a certain day of the week or month, and 
make preparations for its reception accordingly, fre- 
quently modifying their arrangements of business or 
pleasure by its indications. If she goes out or to bed, 
the woman makes ready for its reception by applying 
the napkin, used as a T bandage, to imbibe the fluid, 
w'hich, but for such precaution, would frequently soil 
her dress, or expose her to deep mortification by falling 
down to the ground ; for it should be remarked that the 
discharge, in a good many subjects, appears suddenly, 
and is quite free from the first moment, whereas in 
general it commences by slow degrees, increasing in 
abundance at the end of the first day, and declining on 
the last. Among the thousands of females who are 
seen in the streets of a populous city, how very rare is 
the occurrence of even the slightest exposure of their 
state from soiling or staining any part of their dress ; 
which leads me to infer, that, even the most loose and 
reckless women retain a latent spark of modesty upon 
this point, amid the wreck of morals, and in the greatest 
depths of degradation and misery. 

I am well aware that some persons are met with (very 
careless people certainly), who take no other precaution 



44 MENSTRUATION. 

against exposure than to put on perhaps a thicker or an 
additional petticoat ; but this can only happen in those 
who are scantily regulated ; not a few persons, in the 
most perfect health, being compelled to change the napkin 
at least twice, or even thrice in the twenty-four hours. 

A little time only would be required to show that this 
natural office is, and has been the object of very pecu- 
liar regard, in ancient and modern times ; and I am not 
at all surprised that some superstitions are still to be 
met with, in an enlightened age, on a subject which 
appears to have the greatest influence upon the health 
and stability of the female constitution. 

Such is the sensibility of the sex in regard to the 
privacy required in respect to this office, that it is ex- 
tremely rare for physicians to hear any person of refine- 
ment speak of it in direct terms : such a person gene- 
rally alludes to, rather than pronounces its name ; and 
if we may judge from an incident in the beautiful story 
of Jacob, the modest delicacy of the female was not less 
in the patriarchal ages, than in our more refined period 
of the world. When Jacob fled from his fatlier-in-law 
Laban, Rachel hid the images which her husband h-id 
embezzled, under the camel's furniture, and sat upon 
them ; so that when her enraged parent overtook the 
fugitives, he searched every where for them ; but Ra- 
chel said to her father, " Let it not displease my lord 
that I cannot rise up before thee, for the custom of 
women is upon me." Gen. 31, 35. This incident 
shows that the same delicacy on the part of the female, 
and the same deference and respect on that of the male 
existed in that remote age as at present ; and it is M^ell 
known that this sentiment is nearly universal, without 
exception even of savage and barbarous nations or tribes. 
It is certain that a deep conviction of its importance 
exists every M^here ; and the prevalence of that convic- 
tion doubtless depends on the fact that it does exercise a 
powerful influence upon the health and happiness of the 
female. 

The Jewish law for women under these circum- 
stances was very strict; and it is perhaps a traditional 
sentiment, that still commands, during the menses, a 



MENSTRUATION. 45 

total separation of the woman from the haunts and busi- 
ness of the male, among some nations of the North 
American Indians, as well as certain oriental tribes. 
There is a very prevalent opinion, even among our own 
people, that the presence of a woman with the cata- 
menia is sufficient to cause the putrefaction of meats, 
the coagulation or souring of milk, and the failure of 
sauces, &:c. While I suppose that such opinions are 
pure superstitions, I have been surprised with attempts 
made by good writers to explain the facts of such influ- 
ences, which is at least equivalent to an acknowledge- 
ment of their existence. 

The foregoing remarks might perhaps suffice to show 
to the reader, that a great deal of caution is demanded 
upon all occasions, where the state of the menstrual 
office becomes the subject of his investigation; and I 
need hardly observe that queries should be rather ad- 
dressed to some third party than to the patient herself, 
particularly if she be young and inexperienced. 

The ovaria of the female are not considered to be 
developed until puberty ; and they are supposed to 
undergo a change of density from and after the " certain 
age" at which the menses cease. These organs, it is 
probable, exert a controlling influence upon the function 
now under consideration. It is curious, therefore, to 
compare the male and female in view of this subject. 
If we examine two children of equal age, stature and 
fortune, the one male and the other female, we shall 
find that they present few differences, except as regards 
their sexual conformation. They are alike in the re- 
spects of the brain and nervous system ; the circulatory 
and digestive apparatus ; the respiratory and secreting 
offices ; the kidneys, spleen, glands, members, fancies, 
appetites. They breathe the same air — live on the same 
food — and think and act alike. The signs of puberty at 
length become manifest, and the female is suddenly 
transformed from the girlish to the womanly estate ; a 
transformation not less remarkable from the changed 
appearance it produces in the corporeal than in that of the 
moral system. 

The age of puberty is also marked by considerable 



46 MENSTRUATION. 

changes in the state of the male, but there is a point 
in which they widely differ. The female discharges, 
from one of her organs, a few ounces of a sanguineous 
fluid, which is the first of a series of near four hundred 
instances of a like occurrence ; upon the regular repe- 
tition of which her health, and even her existence may 
depend ; while the other never suffers any such discharge, 
nor does he need any. Both subjects attain to the age 
of forty-five years, and from thenceforth the female, like 
the male, suffers no discharge, and needs none. She 
enjoys better health, and is in a more natural state with- 
out it than with it. The character now becomes more 
and more similar to that of the male, from whose moral 
likeness she deviated with the first eruption of the men- 
ses, to return to it after their final cessation. 

I am unable to say what precise influence upon these 
conditions is exerted by the ovaria ; but it seems not to 
admit of a doubt that they are greatly concerned in giving 
rise to the moral and physical peculiarities of the sex ; 
and in this view they become objects of interest to the 
medical practitioner. 

Women deprived of the ovaria, neither menstruate 
nor bear children. They are also incapable of concep- 
tion antecedently to the development of the ovary and 
the appearance of the discharge. Again, in advanced 
age, the ovaria become much shrunken in size, con- 
densed, and marked by rugae and botryoidal projections, 
which change is probably the cause that they can no 
longer furnish the objects of fecundation. Hence it is 
inferred that the ovaria are very intimately concerned 
with the function of menstruation. All discussion of 
the question, how those organs exert such a potent sway, 
is perhaps worse than vain ; nevertheless, I cannot re- 
frain from the remark, that the highest erotic excitement 
is produced in the ovaria themselves, and is dependent 
upon them ; and that the venereal appetite ceases with 
their removal or destruction ; but the whole genital appa- 
ratus being a single system of organs, destinated to the 
performance of one of the most indispensable functions 
of the race, viz. that of reproduction, I apprehend that 
we shall not be very wide of the truth in supposing that 



MENSTRUATION. 47 

a periodical erethism of llie ovaria is communicated to 
the uterus itself, and results in the effusion from its ves- 
sels of a sanguine fluid, once a month. 

I here repeat very distinctly, that women alone men- 
struate; yet many other mammalia have regular erotic 
periods or seasons, which are marked, among other 
symptoms, by a sanguineous discharge from the geni- 
talia, an evidence of the preparedness of the system for 
the reproductive processes. 

The erotic periods of many of the mammalia, birds 
and fishes, as well as insects, are very well defined. 
The excitation of the nervous and sanguine system is 
very plainly to be discovered in them at those seasons, 
and a secretion of sanguineous fluid then takes place 
from the organs of many species of animals. If such 
periodicity, with long intervals, may exist in one, why 
may not a similar periodicity, having the same ultimate 
object, the reproduction of the species, occur with much 
shorter intervals in another order or species? It is 
almost universally understood, that the catamenial act is 
in a great degree related to the reproductive faculty, be- 
ing designed to renew or restore, or maintain its energy, 
until the period of existence when it ceases to be required. 

I think it is scarce necessary for me to say that I do 
not attribute to the female who is menstruating any in- 
crease of the sexual appetite before, during, or after the 
flow of the menses, as is the case in the animals I have 
alluded to above. Nothing could be further from my 
intentions than to express such an opinion. It is, how- 
ever, quite possible to believe (a common belief) that a 
greater physical aptitude for fecundation exists just after 
each repetition of the menses than before it ; whereas, 
such physical aptitude implies no moral state, no senti- 
ment, no passion. 

What is the proximate cause of the periodicity, I deem 
it bootless to inquire ; since this, like most other vital 
processes, has a sort of metaphysical subtlety, which 
defies all endeavour to grasp or retain it. 

I am the more disposed to rest on the hypothesis above 
stated, as I cannot perceive the grounds of the doctrine 
of plethora, whether local or general, as causative of the 



48 MENSTRUATION. 

menses. This doctrine gives no greater satisfaction to 
the mind than that of lunar influence, or Dr Cullen's 
notion of habit. 

General plethora cannot be its cause in those females 
who, notwithstanding very great weakness and exhaus- 
tion, continue to witness the regular return of the flow. 
The opinion that the discharge is necessary to give to 
the system the habit of creating a superabundance of 
blood, in order that it may become qualified to produce 
a supply sufficient for the pregnant condition, is at va- 
riance with our observation of facts in other animals, 
who do not have catamenia, and yet conceive and bring 
to perfection their offspring, failing as seldom perhaps as 
the more highly organized human female. In the midst 
of the difiiculties surrounding this subject, resort is had 
to whatever circumstances may seem to throw an addi- 
tional light upon it; hence, the speculators who find 
that a habit of plethora is requisite for the pregnant 
woman, have no difficulty in explaining how that ple- 
thora is kept within bounds, nor how natural it is for the 
author of nature to have so constituted the sexual organs, 
as, by means of the menses, to keep up the disposition to 
excessive haematosis as long as the female remains liable 
to pregnancy. But since the other orders of animals 
possess the reproductive faculties in as eminent a degree 
as the sex, I do not think that the idea of an habitual 
tendency to plethora, provided against the contingency 
of pregnancy, can hold as regards them ; for it must be, 
and is, equally untenable in relation to the analogous 
state in all orders of animals. 

It is certain, that in the course of medical practice we 
are often compelled to take blood from the veins of a 
patient who is on the eve of menstruating, and that too 
without in the slightest degree disturbing the regular 
course of the function; but it is considered advisable 
always to refrain from the lancet, if possible, on such 
occasions, since the failure of the natural office, that 
sometimes is observed to follow venesection, may be 
succeeded by long continued derangements thereof, to 
the serious detriment, distress, and danger of the patient. 
I have frequently suspended an order for venesection, 



MENSTRUATION. 49 

upon considerations of this sort; but I must add, that 
where the necessity for bleeding is pressing or decided, 
Tio considerations of the kind ought to have any force 
whatever. 

Upon the question of a local plethora, very little is to 
be added to what I have said above. Nothing is truer 
than that in the vast majority of women, no visible modi- 
fication of the nervous or vascular systems can be ob- 
served to take place upon the catamenial occasions. The 
discharge appears, continues, and ceases ; and the female 
feels nothing different from her ordinary sensations. 
Many there are who labour, during a part of the period, 
under symptoms of congestion of the pelvic viscera ; 
symptoms which vanish with the discharge ; but all such 
are rather pathological than physiological states, and 
ought not to be taken into the account of the causes of 
the catamenia. 

Writers speak of a greater redness and fulness of the 
womb and the ovaries, as occurring during the catame- 
nial flow : to all such, the question might be very pro- 
perly addressed, who has seen the womb and ovaries in 
this predicament? The post mortem results are often 
fallacious, and cannot pretend to declare what is the 
normal aspect for an average of myriads of cases. 

It was anciently supposed, and the suspicion still lurks 
among the darker and more ignorant part of mankind, 
that the phases of the moon exercise a potential influence 
upon this curious function. It would seem to afford a 
sufficient reply to all such suggestions, that neither the 
phases nor culmination of the moon ought to be charged 
with such contradictory powers as to effect in one or one 
thousand what they prevent or nullify in the million : 
some women begin to menstruate each hour of every day 
in the year. 

Considering then, as I do, that the menses are not to 
be explained upon the grounds of general plethora, local 
plethora, or lunar influence, I am equally ready to reject 
the idea that it has been derived from habit, and was not 
originally a female function, but a state superinduced 
upon the constitution by the habits of civilized life. The 
oldest records that we have show, at least, that it was 



50 MENSTRUATION. 

customary in the oldest periods of time ; for Sarah, the 
wife of the great patriarch, was old and " well stricken 
in years, and it had ceased to be with Sarah after the 
manner of women," as we are told in Genesis, chap, 
xviii. V. 2. This passage shows that Sarah was 'regu- 
lated early in life, and had ceased to be so at " a certain 
age :" and the miracle of her pregnancy was so much the 
greater, as it was not customary for women to bear chil- 
dren after the cessation of the menses. So that the 
character of the female constitution has undergone no 
change, in this relation, during the long lapse of centu- 
ries since the patriarchal age. 

Finally, to say that the menses are caused by a phy- 
sical necessity is a transmutation of terms : the other and 
equivalent expression being, simply. We don't know ; we 
don't understand. 

It is far more profitable to inquire what are the sources 
of the discharge. When a woman becomes pregnant, 
she almost universally ceases to menstruate. The womb 
becomes occupied with the ovum, and the canal of the 
cervix is plugged up with mucus, or filled with a mass 
of decidua. Hence, as no menstruation takes place 
where the womb is filled with the ovum, we may right- 
fully infer, that the elimination of the fluid is, by the 
presence of the ovum, prevented from taking place in its 
cavity ; and that, as the vagina, still unobstructed, does 
not yield the discharge, it must be evident that its seat 
ean be nowhere except in the womb. Again, in cases 
of procidentia uteri, where the orifice of the womb juts 
out beyond the vulva, the fluid has been seen to issue 
drop by drop from the os tincae ; and lastly, persons 
dying during the menses, have, upon dissection, been 
found to have the cavity of the uterus stained with the 
fluid, which could be also pressed out from its surface. 

I am always surprised to hear it contended, that the 
menses are secreted or efl*used from the veins, and not 
from the arteries of the womb, for I see not how such 
an opinion can be sustained either by facts or analogy. 
The veins of the womb have no extremities opening in- 
to its cavity, and we are not aware of any lateral open- 
ings of those vessels communicating with the uterine 



MENSTRUATION. 51 

cavity, in the unimpregnated state at least. Do the veins 
secrete any wliere ? It is not even proved that the bile 
is produced rather by the hepatic branches of the portal 
vessels, than by the extremities of the hepatic artery. 
It seems, therefore, gratuitous to attribute to the veins of 
the womb, a function of secretion or periodical effusion, 
which is not known to exist in any other veins of any 
other part of the system. 

Haller was of the opinion that we ought to assign to 
the arteries the source of the menstrual blood, while the 
lochial blood ought to be attributed to the ruptured veins 
of the womb ; but I venture the remark that it is not yet 
settled that any veins of the womb are ruptured, as a 
regular and usual occurrence in labour. 

That the source of the menstrual discharge is in the 
womb itself, might be considered conclusively settled 
were it not that the discussion is occasionally revived by 
our finding women to menstruate regularly throughout 
an entire pregnancy ; one example of which has fallen 
under my own observation. For the most part, those 
women who menstruate during pregnancy, continue to 
do so only until the seventh month, and cease to see any 
thing from that time. I can well conceive that such a 
discharge might take place, if not from the vaginal sur- 
faces, at least from the unoccupied portions of the cervix 
uteri, both interior and external. If we reflect upon the 
great laxity of the union betwixt the membranes of the 
ovum and the lower part of the uterus, we need no great 
amount of credulity to permit the belief, that menstrua- 
tion may occur from the lower points of the womb, 
which are, in many individuals, but very slightly con- 
nected with the apex of the ovum. • That connection is, 
undoubtedly, in many cases destroyed long antecedently 
to the onset of labour. Those who will not accept of 
the above hypothesis, are compelled to resort to the no- 
tion, that a vicarious menstruation is effected by the 
vagina itself, and it is quite possible that the upper por- 
tions of that tube may be the source of the discharge in 
some of the cases of its occurrence in pregnancy. 

The first issues are sero-sanguine ; they become more 
decidedly like blood in the course of some hours ; con- 



52 MENSTRUATION. 

tinue so during the greater part of the period ; grow 
paler and paler ; and, at length, cease entirely, leaving 
the surfaces bedewed by their ordinary excretions. It i& 
a question whether pure blood is discharged. The major 
part of the physiologists in our country, regard it as a 
secretion resembling blood, but not containing fibrine or 
the coagulable principle. There is no doubt that, in the 
general, no clots or shreds of coagtila are observable ; 
nevertheless, Madame Boivin, whose knowledge of the 
whole topic is not inferior, perhaps, to that of any other 
writer, declares that it is blood like that from a vein. 

" La qualite du sang des menstrues, ne parait pas 
different de celui qui circule dans tout le systeme, lorsque 
la femme est saine, bien conformee, et qu'elle fait usage 
des moyens que la sante et la proprete exigent." — Mad. 
Boivin^ Art. des Ace. 105. 

Haller says : " Sanguis menstruus de sana, neque 
immunda foemina, rubore, calore, odoris absentia, nihil 
ab alterius fceminae sanguine differt. Lentorem aliquem 
possit mucus admistus addidisse." — Physiologia, lib. 
28, sect. 3. 

The few opportunities I have had of observing the 
appearances of the catamenial fluid, have been insuffi- 
cient to enable me to come to positive conclusions : since 
healthy women admit of no such investigation ; and the 
morbid specimens, which are the only ones submitted to 
us, are not to be considered as evidence of what occurs 
naturally. Madame Boivin's account is, therefore, more 
worthy to be relied upon than that of any physician 
whatever. Madame B. can speak of the normal, and 
the medical man can only have access to the observation 
of the abnormal state or character of the discharge. 

The argument in favour of the non-sanguineous nature 
of the discharge, drawn from the appearances of the 
fluid when detained for months in the organs, by imper- 
foration of the hymen, is not of an inexpugnable force ; 
nor does it follow that, admitting pure blood to be al- 
ways produced in the case, coagulation of that fluid must 
take place in the womb, giving rise to painful contrac- 
tions like labour pains, or the pains of abortion. It is 
easy to conceive that whatever quantity of fluid should 



MENSTRUATION. 53 

be eflused within the small cavity of the womb, would 
immediately flow forth, in most cases, into the vagina, 
and thus give rise to no more pain than if it were non- 
coagulable. Whenever clots do accumulate in conside- 
rable quantity, they are either very soon discharged, or 
remain many hours in the cavity under severe pressure, 
which serves to express all their serum and most of 
their colouring matter ; so that when the clot is at last 
expelled, it is found to be a mass of whitish fibrine 
resembling organic texture, and very commonly mista- 
ken for a mola, or false conception. I have met with a 
good many specimens of this nature, which have re- 
quired for their expulsion very tormenting pains, like 
those of abortion. These masses of compressed fibrine 
are not unfrequently so firm, and resemble so closely 
certain organic products, that they might readily lead an 
inexperienced observer into error as to their nature. It 
seems to me improbable that the small shreddy coagula 
which we witness in dysmenorrhoea should occasion the 
violent distress that is commonly, and too lightly attri- 
buted to their presence. That distress might, with far 
greater probability, be charged to the inflammatory ac- 
tion of the vessels, which produces the shreddy or deci- 
duous matter in question. 

The era of the eruption of the menses is not the same 
in every region of the globe. In general, the high north- 
ern latitudes are unfavourable for its early appearance ; 
and the low latitudes are connected with its precocious 
appearance. 

We are informed that the girls of the Deccan, of Java, 
Persia, of southern Arabia and of the Barbary States, 
become regular at eight or ten years of age, and are capa- 
ble of fecundation at those early periods. But even in 
these cases I think the testimony extends no further 
than to the instances of certain distinguished and luxu- 
rious families. We are at least certain that the rule of 
precocious menstruation is not invariable for warm cli- 
mates, since the young females of the banks of the 
Senegal are regular at the same epochs with those of the 
young persons of Paris or Philadelphia. Haller men- 
tions the case of a girl in the Alpine valley of Emmen- 

E* 



54 MENSTRUATION, 

thai, who was delivered of a child at her ninth year ; 
and cites examples of the eruption of the menses at birth, 
at three months, four months, the second year, the third, 
fourth, fifth, sixth, seventh, eighth, ninth, tenth ; and 
says that he was daily in the habit of seeing a noble 
lady, of great beauty and wit, who was then in her ninth 
year, and who had menstruated regularly for some years 
past, without any injury to her health. She was very 
small and delicate. 

A lady lately informed me that she was intimately 
acquainted, at Maracaibo, wath a Spaniard, who gave 
birth to twins before she was fourteen years old, having 
previously given existence, in her first labour, to a 
healthy child, at which time she was not thirteen years 
of age. 

In a few individuals the first eruption occurs at a late 
period, as at eighteen, nineteen or twenty years. Such 
persons suff'er no sanitary inconvenience from the non 
arrival of the discharge, but its retardation is rather the 
result of a slow and languid development of the powers 
of the economy ; and its tardy appearance is more a 
consequence than a cause of some constitutional defi- 
ciency which may be supposed to exist in such persons. 
The Lapland women and those of the arctic regions, are 
well understood to be very late and very scantily regu- 
lated. The long enduring and severe frosts of those 
inhospitable climes are the sufficient causes of this pecu- 
liarity of their female inhabitants. 

It is commonly believed that women who take very 
active exercise, and are engaged in laborious offices in the 
country, are far less abundantly regulated than the luxu- 
rious and pampered inhabitants of cities. There is also 
good reason for believing that northern women, trans- 
ported to the hotter regions of the globe, suffer a very 
great increase of the catamenial flow, so as, indeed, to 
be brought occasionally into great danger therefrom. 

I do not consider it out of place here to remark, in 
connection with this subject of scanty menstruation, that 
cold countries are not so favourable to the increase of 
population as the milder regions of the south. The 
reproductive faculty is not so vigorous where, in conse- 



MENSTRUATION. 55 

quence of protracted and severe frosts, the productions 
of the soil are not sufficiently abundant to support an 
immense population. We are accustomed to hear much 
of the " populous north" and of " northern hives," but, 
if in past ages, irruptions into the south have been made 
by vast hordes, who have seized upon its fertile plains 
and crowded cities, such irruptions ought not to convey 
to us an idea of the greater productiveness of the race in 
those northern regions from whence the barbarians 
issued. They abandoned their deserts en masse, with 
their wives, children and cattle, and their greatest armies 
were small, in comparison with the conflicting hosts 
that have met in our own days in every part of Europe. 

The same differences that are observable in different 
women, as to the first appearance, are noticeable in what 
regards the final cessation of the menstruae. They are 
expected to cease at forty-five ; but many individuals 
lose them at thirty-five, or even earlier; while on the 
other hand, examples are recorded of persons in whom 
they continued so late as sixty, seventy, eighty, ninety, 
one hundred, and even to one hundred and six years. 
See Haller^s Fhysiologia, torn. vii. 141. 

Persons are occasionally met with in whom, after 
their cessation for years, they have reappeared, like the 
new teeth, new sight, and restored hearing, now and 
then recorded of aged people. Those in whom the 
office continues until a late period in life, are probably 
capable of conception while ever it lasts : children have 
been born of mothers above sixty years old. 

As in the commencement, so in the cessation there is 
generally a gradation. In the very young female, the 
first show is commonly only a pale serum, which doe^ 
not give place to the high coloured and thor )ughly cha- 
racteristic discharge, until several periods have elapsed, 
and the law of the sex acquires full dominion over her. 
When, too, a woman approaches near to the great cli- 
macteric, the age in which she is to become (technically) 
an old woman, the courses become irregular, returning 
twice or thrice in a month, then ceasing for a few 
months, and afterwards recurring with great profuseness. 
This state, which from its uncertainty is called dodging, 



66 MENSTRUATION. 

continues' for a year or longer, when the function ceases, 
to return again no more. In many it stops suddenly ; 
and I have been informed by some persons, on whom I 
could rely, that they had continued to feel perfectly well 
throughout the whole of this critical age ; the discharge 
had stopped without return, and their health remained 
unchanged in the smallest degree. Not a few persons, 
however, will be met with, in whom disorders arise that 
are readily attributed to the cessation or decline of the 
catamenia. 

Certainly no long disquisition is necessary here to 
show why a female should have troubled health about 
this time of life. It is a time of crisis. The menses 
have exerted a potent sway, and even dominion over her 
economy for thirty years ; their slightest disorder or 
obstruction has been accompanied with headach, colic 
pains, fever, indigestion, and other symptoms, that 
vanished upon the re-establishment of the natural issues. 
As a general rule, no long continued habit can be sud- 
denly broken off without more or less inconvenience. 
The suppression of an old seton, the healing of a long 
open ulcer, are not unfrequently followed by troublesome 
consequences ; and it appears perfectly consonant with 
reason, as well as with experience, that women should 
become at this time the subjects of dropsy, atrophy, con- 
sumption, cancer, and liable to a general break-up of the 
constitution. Prudent persons should be very attentive 
to the first manifestations of disordered action at this 
term ; and he is but a reckless practitioner who puts off 
the complaints of such patients, with the assertion that 
" it is only the change of life," and thus, like those who 
think that the beginning of consumption " is only a 
cold," allows his patient to be immedicably diseased, 
before attempts are made to avert or restore. There is, 
no doubt, a very great responsibility resting on those 
who, by failing to bestow a proper attention upon the 
complaints of women at this crisis, suffer them to become 
fixed ; whereas they might have been easily averted or 
cured, by prompt and diligent attention in their incep- 
tive state. 



CHAPTER VI 



AMENORRHCEA 



If a girl reaches her fifteenth or sixteenth year, and 
falls into disordered health, her catamenia not making 
their appearance, she is commonly presumed to be 
labouring under Amenorrhoea, to which is attributed the 
vicious state of her constitution, and which it is supposed 
must be removed, in order to admit of a more perfect 
play of the powers of the economy. Those who have 
never had it are said to be labouring under emansio 
mensium, or retention of the menses ; while those who 
have already been regulated but are now deprived of it, 
are said to be affected with suppressio mensium, or 
amenorrhoea. 

There are many causes that may suffice to prevent a 
young person from menstruating, when she attains the 
usual age for it, besides that general torpor or slowness 
of development of which I have already spoken. Thus 
there may be a total absence of the uterus ; or the uterus 
may possess a faulty conformation. The canal of the 
cervix may be imperforate. The ovaria may be want- 
ing. The vagina may be imperfectly developed, or of 
monstrous form. The entrance to it may be closed by 
adhesive inflammation, or by an imperforate hymen. 

If the non appearance, at due time, of the menses 
should depend upon a general deficiency of the vital 
forces, it would be easy to verify the cause, by carefully 
observing and comparing the play of the great functions ; 



58 AMENORRHCEA. 

and upon their being found to be free from any special 
disorder, the inference would be strong in favour of a 
mode of treatment calculated to excite and invigorate the 
whole system ; or the prudent physician might advise 
that no treatment should be adopted, but rather that con- 
fidence ought to be placed in the powers of nature, which, 
in proper time, can overcome disorders of this particular 
class. But in all cases of emansio mensium, it is of the 
last importance for the medical adviser to reflect carefully 
upon the circumstances of the patient before instituting 
any plan or method of cure. 

Is it not notorious among the profession that the medical 
treatment of amenorrhoea is eminently empirical, unsatis- 
factory, and unsuccessful ? It must be admitted, that the 
subject is, in a practical view, a very difficult and embar- 
rassing one ; nevertheless, I feel much persuaded, that 
a more considerate, and a more rational attention devoted 
to the cases which fall under our notice, would enable 
us more frequently to administer relief, without being 
obliged to resort, as we are now, often to every one of 
the menagoga in succession, and in vain. 

A blister applied to the thorax often cures a pleurisy, 
upon the principle that " pars dolens trabit," or the 
principle of counter irritation; it is equally true, that 
any considerable external or internal fixed irritation may 
prevent or counteract the natural tendency of the system 
to produce catamenia. A wet stocking, a draught of 
cold and damp air, produces^ in the skin a certain condi- 
tion which frequently serves to prevent or arrest the 
menstrual offices ; a fortiori, therefore, some latent dis- 
order of an important viscus or organ, would scarcely 
fail to interrupt, or, in some measure, trouble this deli- 
cate depurative act. Hence, instead of opening the 
great volume of the Materia Medica and searching 
under the head of Menagoga for some specific means 
of removing the difficulty, let the medical man care- 
fully study the state of the patient's health, endeavour- 
ing by repeated inquiries to learn the case of the seve- 
ral great functions, and that of numerous minor ones, in 
order, in their excess or deficiency, to find a cause of 
the amenorrhoea, which he will then be able to treat 



AMENORRHCEA. 59 

with the reasonable methods that a perfect understanding 
of the case will suggest to him. 

It is not to be supposed that if a woman's constitution 
can be brought into healthful play in all other regards, 
she will be vicious or disordered in this instance, of 
amenorrhoea. I grant that sudden arrests or stoppages 
may take place from slight and perhaps local causes ; 
but I speak now of the instances of rebellious obstruc- 
tions. I wish to impress the idea that a woman is not 
unhealthy because she fails to menstruate, but rather, 
that she fails to menstruate because she is unhealthy. Let 
us suppose a case. A young woman has her feet wet the 
day preceding that on which she should be regular. She 
gets a rigor, succeeded by fever, intense headach, 
vomiting, pain in the loins and hypogastria, &c., all 
which phenomena are results of the violent reaction of 
the system upon the morbific impression of cold and 
dampness. The symptoms frequently appear before the 
time of the flow, and they continue with more or less 
severity until the show takes place, when they are im- 
mediately relieved; or, as is often observed, they are first 
relieved by a venesection or purge, after which the show 
makes its appearance ; or they may wholly prevent the 
menses from coming down, and be the first instance of 
a long series of failures. It appears to me to be quite 
clear that in a major part of such cases as I have sup- 
posed, a sound philosophy leads us to endeavour to sub- 
due the constitutional disturbance by the proper means 
for that end, so that the patient may recover in order to 
menstruate, and not that she may menstruate in order to 
recover. 

The treatment of acute cases by venesection, purgatives, 
warm baths, camphor, opium, &c. &c., shows conclu- 
sively that physicians appreciate the real principles of 
such practice, and it is therefore the more suprising that 
they are many times, in chronic cases, observed to aban- 
don reason, and follow the most empirical, crude and 
indigest notions of treatment. 

Of all the great functions, none, I am persuaded, is so 
intimately related to the menstrual affections as that of 
the circulation. Let its condition be fully investigated 



60 AMENORRH(EA. 

and understood : is there an improper momentum of the 
blood directed upon other organs? is it excessive with- 
out particular determinations ? is the movement of the 
blood enfeebled ? does the patient, by exercise or labour, 
compel the circulation in the capillaries of the muscles 
to be sufficiently active and free to obviate the tendency 
which is acquired to the central or visceral congestions 
and engorgements so ordinary in the sedentary and lazy ? 

Inquiries should always be made concerning the state 
of the hepatic functions. Is there a torpid or obstructed 
portal circulation ? and can the whole venous circulation 
of the chylopoietic viscera collected in the portal vein 
be vicious without in some measure affecting that of the 
genitalia ? If the bile is acrid, or weak, or deficient, it 
will cause disorders of the alimentary canal, that must 
retard or hinder the natural tendency of the vital move- 
ments in the womb and ovaria. In such circumstances, 
attempts made to restore the health by forcing medicines, 
for of such are most of the class menagoga, will rather 
serve to fix and rivet the irritation, than to remove it; 
at least, they are generally fruitless. If she be me- 
naced with consumption, for example, she early loses 
the catamenia, and a pressing demand is made upon the 
medical attendant for its restoration ; but rash attempts 
to effect it by means of emmenagogues, are quite as apt 
to bring on haemoptoe, as the more natural discharge 
which is the object of so great solicitude. 

The skin has an intimate relation, by sympathy, with 
the whole of the mucous system, whether respiratory, 
digestive, or genito-urinary. It cannot be, therefore, too 
carefully looked to. In amenorrhcea it is, for the most 
part, dry, pale, and not sufficiently elastic. In extreme 
cases it becomes so much altered, so opake, harsh and 
disagreeable, as to attract the attention very peculiarly. 
Its chlorotic colour gives to bad cases of amenorrhoea 
the title of green sickness, or chlorosis. Such a state 
must be inseparable from an engorged and obstructed 
condition of the viscera ; which, whilstever they are op- 
pressed and crushed under the masses of blood imposed 
upon them, can never cease to be the centres of move- 
ment for the sanguine as well as nervous systems, and 



AMENORRHCEA. 61 

thus divert the tendencies of fluxion that ought to exist 
towards the uterus. If we recall the blood to its legiti- 
mate channels, by restoring to the skin its proper ener- 
gies, in removing the visceral obstructions or torpor, the 
amenorrhosa ceases, and the rate of all the functions 
becomes equalized. Moderate bleeding, local or gene- 
ral ; purgatives ; an emetic ; frictions with the flesh brush, 
or with salt, or dry mustard ; the warm bath ; a blister 
judiciously timed ; the wearing of flannel next to the 
skin ; exercise on horseback ; walking, as a regular 
duty ; dancing and various gymnastic amusements — all 
these may be safely looked to as means of relief, far 
more to be depended upon than the empirical adminis- 
tration of drugs, whose modus operandi is, in general, 
but darkly suspected, and never fully understood. 

The removal of corsets and all tight bandages or 
dresses, and the rigorous prescription of flannels, stock- 
ings, shoes, shawls, &c. must not be deemed unworthy 
of the physician's attention, any more than the dietetic 
regulations, which should always correspond to the 
wants of the case for the time being. 

After having subdued or mitigated the local disorders, 
and the constitutional disturbance arising from them, if 
the sanguine apparatus of the womb still fails to act 
properly, in yielding the catamenial discharge, the time 
is arrived for resorting to the emmenagogue articles. 

It is a general complaint, that we have, as yet, no good 
emmenagogues ; and that the uncertainty in regard to 
their operation, is as great as that of the diuretics. It 
would seem, indeed, that the materia medica includes 
no article that exercises an immediate or specific action 
upon the womb, if we except the secale cornutum ; and 
even of its powers much question is still made, notwith- 
standing a great deal of experience already had of its 
emplo3nuent. 

Among the articles of the materia medica, those are 
most to be relied upon, as emmenagogues, which exert 
an indirect influence on the womb by sympathy with the 
bladder or rectum : such are cantharides and aloes ; by 
the administration of either of which, we have it always 
in our power to produce a very considerable excitement 



62 AMENORRHOEA. 

in the pelvic viscera. The action of the womb upon the 
rectum and bladder, is well known to be very decided : 
tenesmus, dysuria, and other graver affections accom- 
pany some of the uterine diseases. So, too, when the 
bladder is highly irritated by cantharides, or the rectum 
by drastics, the uterus partakes of the excitation or in- 
creased vital action. In fact, it is found that aloetics 
and cantharides are among the most successful of the 
emmenagogues. I am convinced that these articles are 
ordinarily administered without sufficient boldness, and 
that they ought to be freely employed whenever they are 
indicated. 

The operation of these medicines upon the womb may 
be greatly promoted by the occasional employment of 
the hip-bath ; the pediluvium with infusion of mustard, 
and full draughts of infusion of some aromatic herb, espe- 
cially the pulegium. The tincture of black hellebore, 
in doses of a teaspoonful, has often been in my hands 
followed by a restoration of the menstruae. The dose 
should be repeated every six or eight hours, being fol- 
lowed by the use of an aromatic infusion. The volatile 
tincture of guaiacum, the decoctions of seneca, of madder, 
of serpentaria, the tinctures of castor, of aloes and myrrh, 
and the chalybeate preparations are all justly chargeable 
with the great uncertainty as to their operations, of which 
Dr Cullen so loudly complains. They undoubtedly do 
succeed now and then, when happily timed, and furnish, 
at least, an armamentarium medicum, from which the 
enlightened and judicious practitioner can select the 
means of combating the principal disorder, after he shall 
have first mastered the constitutional disturbances, which 
in general offer the most considerable portion of the 
resistance he has to contend with. 

The reader will have remarked that I have given but 
a penurious detail of remedies for amenorrhoea, but I 
shall excuse myself, on the ground that experience has 
shown me the little dependence that is to be placed upon 
the drugs that are dignified with the title of menagoga; 
and I shall entrench myself, upon this point, in the 
works of Dr Cullen, to whose Materia Medica I refer 
those who, aware of that great man's perfect candour 



AMENORRHEA. 63 

and consummate judgment, will no longer feel disposed 
to censure my meagre announcement of medicinal 
agents, when they shall have seen how utterly dissatis- 
fied the Edinburgh professor was with the entire falla- 
cious class of emmenagogue articles. 

Dr Cullen says, in speaking of the emmenagogues, 
that they are " a set of medicines the most unfaithful ; 
and very frequently disappointing our expectations from 
them. The writers on the materia medica, both ancient 
and modern, particularly the former, mention many 
medicines as emmenagogues, and I have employed a 
great number of those recommended by them ; but I 
have been so very often disappointed of the wished for 
effects, that I have ventured to allege that the ancient 
writers had not, on this subject, spoken from experience. 
These disappointments that I have met with, I find to 
have also happened to my fellow practitioners : I have 
not, amongst the most experienced, found any one who 
does not acknowledge his failures in employing the em- 
menagogue medicines recommended by writers ; nor who 
does not own that he cannot, almost in any case of 
amenorrhoea, with much confidence, promise success in 
curing it."— Mz^. Med. vol. 2, page 407. Edit. Phil. 
1812. 



CHAPTER VII 



DYSMENORRHCEA 



The term Dysmenorrhcea is applied to those cases in 
which the act of menstruation is accompanied with pain 
in the region of the uterus. 

The disorder varies in intensity in different indivi- 
duals : being in some very slight, and occurring only 
occasionally, as in consequence of cold or some tempo- 
rary derangement of the health ; whereas, in others, it 
constitutes one of the greatest sources of distress to which 
the female is ever obnoxious, the menstrual office being 
never performed without agonizing pain. I have met with 
individuals who entertained the greatest dread of the 
approach of the catamenial period, from the certainty they 
had of passing through an ordeal of extreme anguish. 

It is quite common to be told that menstruation, even 
in the healthiest people, is ushered in by certain uneasy 
sensations in the back and loins, and a sense of weight, 
fulness, heat, or aching. In general, these symptoms 
disappear as soon as the discharge becomes free, and they 
leave the female perfectly comfortable throughout the 
remainder of the term. In such slight affections it is 
not common to ask for medical advice, as the subject of 
the disorder generally refers it to nature and time, or 
has recourse to some simple warm aromatic infusion, a 
foot bath, and rest. 

But, a female who has been improperly exposed to cold 
and dampness, may suffer more severely during the cata- 



DYSMENORRHEA. 65 

menial function. The irritation has fixed itself upon 
the uterus, and produces in it a high degree of nervous 
excitement, which may be gradually abated as the excre- 
tion takes place. If the pain and irritation should have 
gone so far as to excite a general disorder of the economy, 
manifested by fever, restlessness, headach, vomiting, and 
pains in the limbs ; an enema, a free bleeding and some 
anodyne dose, such as an anodyne enema, or a pill of 
opium and camphor, with a warm pediluvium, will, in 
general, suffice to subdue all the constitutional manifes- 
tations, while the liberal effusion that follows from the 
womb, in a short time extricates that organ from the 
local embarrassment to which it had been subjected. The 
next succeeding menstruation may be perfectly natural. 
Such a case of simple dysmenorrhcea is not unfrequently 
met with, but it differs widely from other instances in 
which the patient acquires a regular habit of suffering at 
each return of her monthly indisposition. 

Notwithstanding what Madame Boivin says, as to the 
identity of venous blood with that of menstruation, I am 
well confirmed in the belief, that it is far from common to 
observe, in the periodical discharge, any considerable 
amount of clotted or coagulable material; and yet, some 
individuals always find a portion of shreddy matter upon 
the napkin. Such persons always, I think, suffer no 
little pain during the catamenia. This circumstance 
may arise from the difference of coagulability in the blood 
of different people. I have, in a good many instances, 
seen coagula which presented the appearance of com- 
pressed masses of boiled veal ; the red globule having 
been completely broken up, and the colouring matter 
expressed or squeezed out, leaving a reddish white clot 
of fibrine in the organs, which, after a greater or less 
period of time, has been forced out from the womb by a 
real contraction of the fibres of that hollow muscle. The 
violence of the contraction has generally been in propor- 
tion to the size of the clot. One person who was under 
my care, repeatedly discharged such clots larger than a 
black walnut, and with pains no less severe than those of 
abortion, since they effected a considerable dilatation of 
the cervix and os uteri, and required an expulsive force 



66 DYSMENORRHEA. 

equal to what is demanded for the extrusion of any early 
abortion. 

These clots, which result from a true dysmenorrhoea, 
are generally mistaken by the patient for false concep- 
tions, or moles ; from which, however, the attentive and 
skilful observer is able easily to distinguish them by the 
absence of any real organization. 

In a uterus that is affected with a more or less severe 
inflammatory diathesis, the menstrual office is, for the 
most part, accompanied with a very high degree of vital 
action of the organ, causing it to excrete, as in concep- 
tion, a caducous matter that has been supposed to be 
similar to the deciduous coat of the gravid womb. The 
discharge of this decidua is attended with*-severe pain, 
rendered greater, probably, by the excessive irritation of 
the womb, which causes all its contractile efforts to be 
more acutely painful. Such a state of the womb may 
be fully expected to cause sterility, which ceases when 
the gestative organ returns to its ordinary and healthful 
condition. Some of the instances of dysmenorrhoea of 
the kind just mentioned, have been relieved by antiphlo- 
gistic treatment, and the patient has been afterwards the 
subject of pregnancy. 

I have had more than one occasion to know, that in 
the treatment of these disorders, it is highly important 
that the most accurate information should be obtained 
concerning the condition of the womb itself; and I think 
that upon making a proper representation to the patient, 
or her friends, the practitioner's request 'to.' make an 
examination per vaginam will be met by no perverse 
rejection or denial. It is not to be doubted, that where, 
from long continued dysmenorrhea, the womb has been 
the seat of a preternatural irritation and affluxion, the 
organ will, in many instances, be found tumid and pain- 
ful. Such a state as this, when once fully ascertained, 
will throw much light on the nature of the treatment to 
be adopted under such circumstances as these, which are 
to be met with far more frequently than is generally 
conceived of. 

Rest, in a recumbent posture, continued for the space 
of several weeks, tends greatly to the subduction of the 



DYSMENORRHCEA. 67 

congestive and inflammatory disorder of the womb. The 
patient ought to be made fully aware of the import of the 
term rest in her case ; and, so far as my personal expe- 
rience serves me, I think that it is easy to gain the con- 
sent of the patient to confine herself to a couch or sofa 
for four or six weeks. Under this absolute rest, gi'eat 
good may be expected from the proper use of bleeding, 
whether general or local. The former is always to be 
preferred, where the state of the system makes it allow- 
able ; the latter, or local bleeding, will very properly fol- 
low the general, and may be practised either by leeches 
or cupping. In the use of leeches for the object at pre- 
sent under consideration, we may order them to be ap- 
plied within the vulva, or on the groins, so as to cover 
the round ligaments, as they issue from the abdominal 
ring. These abstractions of blood are followed by great 
relief, and should be repeated from time to time, accord- 
ing to the state of the case, which ought to be noticed 
by an occasional repetition of the operation of touching. 

During the course just now recommended, the patient 
should use a purgative or aperient dose every third or 
fifth day ; such as a portion of blue pill and rhubarb, or 
the sulphate of magnesia. Those days in which- no 
aperient is given should be employed for the adminis- 
tration of antimonials, in such form as the physician 
may select. 

I shall take the liberty of stating here, that I am in the 
habit of preferring the precipitated sulphuret of antimony, 
combined with small portions of camphor, and sometimes 
with morphia or opium. This article I find to be as 
little offensive to the stomach as any other of the anti- 
monials, and it may be used for a considerable length of 
time without inconvenience. Where it may be deemed 
necessary to add to it some more powerful deobstruent 
article, the blue mass, or calomel, may with great pro- 
priety be employed, in moderate quantities, the patient 
being always kept under a strict inspection, in order that, 
upon the least appearance of the constitutional excite- 
ment peculiar to those who are under the use of mercu- 
rials, the article may be at once withdrawn. 

The diet ought to be carefully regulated. Bread and 



68 DYSMENORRHCEA. 

tea, or milk, constitutes a sufficient breakfast and supper. 
The patient may be allowed to take mutton, or chicken, 
or fish, every other day, along with wholesome vegeta- 
bles and fruits ; while on the alternate days the dinner 
ought to consist of bread or rice puddings, plain boiled 
rice, gruel, or the preparations of sago, tapioca or arrow- 
root. 

A semicupium, or a whole bath, of a moderate tempera- 
ture ought to be used every fourth day. These precau- 
tions, in addition to a careful adaptation of the dress to 
the state of the weather or season, will scarcely fail to 
recover the uterus from its irritated and abnormal con- 
dition, so that it will perform its menstrual function with 
all' the regularity and facility that we have a right to 
expect from that organ, when in its best and most health- 
ful state. 

I cannot pass over this part of my subject without 
adverting to the statements made by Dr John ^lackin- 
tosh, of Edinburgh, in relation to the cure of dysmen- 
orrhoea by means of the bougie. 

This gentleman having met with some preparations 
of the uterus, in which the canal of the cervix uteri was 
remarkably small — so small as barely to admit a com- 
mon silver probe, conceived the idea, that, in such a 
state of the organ, menstruation must of necessity take 
place with difficulty: he gave the subject a careful at- 
tention, and concluded that a mechanical dilatation of the 
canal might result in the cure of so painful a disorder. 
Dr M. informs us that he hesitated for some years to 
carry his idea out in practice, until, in the year 1826, 
he met with a remarkable instance, that he details at 
length in his work. Since his commencement with this 
new practice, he has treated twenty cases of dysmenor- 
rhoea, of which eighteen were cured. 

This method is, to introduce a metallic bougie, of a 
small size, into the cavity of the cervix, and carry it up 
to the fundus uteri. In proportion as the treatment 
progresses he uses bougies of a larger size, until the 
dilatation of the canal has become sufficiently ample. 
He applies the bougie from the size of the common 
silver probe up to that of the bougie No. 8. or No. 10. 



DYSMENORRHCEA. 69 

In general no unpleasant symptoms have followed the 
use of the instrument, and the practice eminently de- 
serves the title of successful which produces the cure of 
eighteen out of twenty cases. 

Dr Mackintosh's successful cases occurred as follows. 
Eight were either in young unmarried women, or in 
women in a state of widowhood ; ten were married and 
living with their husbands ; of these ten, seven after- 
wards became pregnant. Dr M.'s very interesting ac- 
count of his method may be found in his Principles of 
Pathology and Practice of Physic. American edition by 
Duff Green, Washington City, 1834. 



CHAPTER VIII. 



LEUCORRHCEA 



Leucorrhcea, Fluor Albiis, or Whites, is a very trou- 
blesome complaint, which, like amenorrhoea and menor- 
rhagia, appears to me to be commonly treated with so 
very little regard to sound medical reasoning, that I 
have resolved to say something of it in this place, from 
which I might, perhaps, have very properly excluded it, 
on the ground that the subject is too copious to be ad- 
mitted into a small work of this kind : it would be im- 
possible to give a full account here of an affection so 
important, and depending upon complications so exten- 
sive and diversified in their nature as the disease in ques- 
tion. My object could only be to state some of the 
generalities of the topic, referring the reader who is 
anxious for more particular information, to the books, 
which are already numerous. 

I shall commence then with the remark, that all 
secreting organs are liable to be so changed in their 
nature or actions, as to produce secretions deviating from 
what is natural, in respect to their quantity or quality. 
The product of the secreting surface of the nares, the 
bronchia, the alimentary canal, are all of them obnoxious 
to very great modifications, when their several sources 
are labouring under various grades or stages of irritation 
or inflammation. We find the mucus of the nose become 
a profuse distillation of hot coryza, or assuming the 
appearance of laudable pus ; bronchial mucus may be- 



LEUCORRHGEA. 71 

come gluey and adhesive, or short and puriform ; or it 
may be tinted throughout with blood ; or it may become 
almost serous, under various states of disease. The 
mucous apparatus of the genitalia, like that of other parts, 
may be affected with discharges morbid in quantity and 
quality. These mucous or catarrhal disorders have a 
general resemblance to each other, whatever be their 
seats or sources. They all compose a group, the history 
of one individual of which serves to throw much light 
upon that of the others. 

I have translated the following passage from Vigarous, 
as containing a very clear and succinct account of the 
origin and progress of a case of Fluor Albus, which ought 
to be read with interest by those who are acquainted 
with that writer's reputation and authority, upon the 
maladies of the sex. Vigarous says, tom. i. p. 235, 
" At first the patient perceives a discharge of mild mat- 
ter, almost always whitish, which moistens the vagi- 
na and escapes drop by drop. She experiences no in- 
convenience, no pain, nor any morbid sensation. Hence 
women, prevented by an excess of modesty, take no pre- 
cautions in this stage, and neglect a disease which at 
this period, is of easy cure, but which soon becomes 
obstinate. Women pass several years in this way be- 
fore the danger is exhibited by severe symptoms. 

"After the lapse of some time, more or less, and after 
all precautions and all remedies have been neglected, the 
urine becomes thick, and according to Hippocrates, 
similar to that of mares, jumentosa. The pulse is 
vermicular ; the discharge becomes so abundant as to 
soak through the napkins which she employs ; the 
matter becomes, successively, greenish, yellow, black, 
and similar to washings of flesh ; it becomes acrid, and 
occasions pain, excoriations, ulcers of the womb ; the 
women take an aversion to coitus; the face becomes 
pale, bloated ; the eyes swell and are surrounded by a 
yellow circle, as in dropsical people ; they lose their 
lustre and become heavy and dull ; the appetite is lost ; 
grief and sorrow take possession of the patient ; the 
senses are weakened, particularly vision ; sighing and 
lassitude, upon the slightest exertion, indicate the greatest 



72 LEUCORRHOEA. 

debility. Gradually the smell of the matter becomes 
insupportable ; the menses flow irregularly, often are 
suppressed; and hectic seizing the patient soon drags her 
to the grave." 

Leucorrhoea is an. exceeding common complaint ; but 
as the vast majority of cases are slight, producing even 
less inconvenience than an ordinary cold in the head, 
physicians are not told of it, and it disappears spontane- 
ously, like other slight catarrhs, leaving the patient in as 
good health as she enjoyed before the occurrence. 
Cleanliness, rest, a restricted diet and an aperient medi- 
cine, suflfice to remove cases of such a slight nature, and 
are spontaneously resorted to by the well informed fe- 
male. 

Unhappily it is not always so simple an affection as 
the one above mentioned ; and when it does become 
rebellious and obstinate, greatly endangers the general 
health of the patient. 

The leucorrhoeal matter may be formed either in the 
cavity of the uterus, or in the vagina, or the inner sur- 
face of the labia ; and much difficulty will exist in en- 
deavouring to ascertain from which of these parts the 
discharge is produced. The diagnosis relative to the 
precise seat of the disease will rest mainly upon the 
nature of the constitutional affections developed along 
with it, and not upon inspection of the par t^ themselves, 
which, even could it be obtained, would not readily yield 
any certainty, except, indeed, in those aggravated forms 
which are connected in the disorganization of the tissues 
that may have become visible or tangible. 

Leucorrhoea occurs at any time from infancy to old 
age. 1 have seen very obstinate examples of it in chil- 
dren of two years old ; and many persons are afflicted 
with it at from fifty to eighty years of their age. I have 
a patient who labours under it in her eighty-first year. 

For the most part the discharge is, in its commence- 
ment, mild, resembling thin buttermilk. As the malady 
progresses, the matter assumes the appearance of pus, 
and at last acquires a greenish hue, like that of gonor- 
rhcea, after which it becomes more viscid and translucent, 



LEUCORRH(EA. 73 

diminishing in quantity, until nothing more is produced, 
than the natural and healthy secretions of the parts. 

In severer examples, the irritation becomes chronic, 
and may continue for a great length of time, with alter- 
nate meliorations and aggravations of the symptoms ; 
until, the constitution feeling the influence of the local 
malady, the health is broken, and the state of the 
patient is now, for the first time perhaps, communicated 
to a physician. 

If it take place in a menstruating female, the discharge 
may either continue all the time the catamenia are flow- 
ing : or it may be suspended for that time, in order to re- 
turn with great violence, upon the cessation of the menses; 
but growing less and less severe as the term for the next 
menstruation approaches. 

The amount of the discharge is, in general, not so 
great as to require the wearing of a napkin ; the patient 
freeing herself by the occasional use of the bidet. In 
some examples the product is very great, soaking through 
napkins and dresses, and occasioning by its tendency to 
putrefaction, the most noisome stench. In some indivi- 
duals, who are careless in the point of cleanliness, the 
nature of their situation is often involuntarily disclosed 
to the medical man by a sort of hospital smell, like that 
from a sore leg ; while perhaps the patient herself, ac- 
customed to the odour, is not in the least suspicious that 
her disorder is known or even surmised to exist. 

A very slight degree of it is frequently met with in 
pregnant women ; but it disappears after labour. In some 
pregnant women the discharge has been observed to be 
enormous, and foetid in the highest degree. I am not 
aware that it is peculiar to any particular stage of preg- 
nancy. 

A good many women are troubled with it after lying- 
in ; and a few examples occurring after parturition have 
proved exceedingly obstinate. I have not found that 
bad, or laborious, or instrumental labours are more likely 
to be followed by it, than others of a perfectly natural 
and moderate character. 

It may take place in consequence of cold or dampness, 
want of cleanliness, debility, local irritation, or preg- 

G 



74 LEUCORRHCEA. 

nancy, venus nimia, pessaries, polypi, or ascarides, 
which occasionally collect in considerable quantity in 
the vagina, having passed into it across the perineum. 
Constitutional disorders tend to involve particular organs 
in disease, and doubtless many examples of leucorrhoea 
may be traced to affections of the generative organs 
arising from distant irritations, as those of the liver, sto- 
mach, (fee. 

The disease is known by the discharge of a whitish, 
a yellow, or green fluid from the vulva ; by paleness and 
sallowness of the skin ; loss of strength ; emaciation ; 
and by pains in the back and loins. Where the malady 
has made great progress, it is capable of subverting the 
functions in general, to a degree which can only be 
accounted for by reference to the powerful control or 
influence exerted upon the whole of the functions by the 
genitalia. The bad cases are those in which the womb 
itself is in fault : for the constitution is frequently found 
to bear, without much distress, a long continued purging, 
or a loss of blood from piles ; whereas it suffers excess- 
ively, if the discharge of leucorrhoea be only somewhat 
profuse. Menorrhagia, too, may be quite profuse in 
some individuals, without causing so great a depression 
of strength or spirits as is occasioned by no very violent 
fluor albus. In all such cases, then, as affect the pa- 
tient somewhat deeply, I am accustomed to think the 
seat of the malady is rather in the womb than in the 
accessory organs, since those organs are far less capable 
of exciting extensive morbid sympathies than the uterus 
itself. 

The great danger of mistake in the case, consists in the 
proneness of medical persons to adopt the views of their 
patients ; and in the present instance, since muscular de- 
bility is one of the most constant phenomena of the dis- 
order, it is very difficult to avoid the contagiousness of 
expressed opinions. If our patients exclaim against 
weakness, we tend to regard them as weak, and act ac- 
cordingly, i. e. by exhibiting bark, port, and other heating 
drugs, whose only inherent tendency is to augment rather 
than abate the local, and, through them, the constitutional 
disorders. The various chalybeate and aromatic tonics 



LETJCORRHCEA. 75 

that are prescribed for the disorders of the menstruating 
organs, I am well persuaded, do as much harm as good, 
and, at least, they commonly fail of success. 

I feel it incumbent on me to reiterate here the opinion, 
tliat medical men too frequently satisfy themselves in 
regard to the pathological condition of these patients, by 
a mere general examination of their symptoms and com- 
plaints. 

The symptoms occasioned by several disorders of the 
genitalia are so similar, that the practitioner ought not 
to trust himself to decide, without the most thorough 
inquiry. I have seen a supposed case of bad leucorrhcea, 
in which the patient, although long under medical' care, 
had never been Touched until I was called to see her ; 
and I immediately learned that the entire cervix uteri 
had disappeared under the destructive progress of a cor- 
roding ulcer. I found on one occasion, an old cork pessary, 
entirely deprived of its coating of wax, which was causing 
a most distressing leucorrhcea, that ceased upon the re- 
moval of the foreign body. A polypus, by its presence 
and pressure, can hardly fail to occasion a degree of 
mucous irritation which cannot be expected to cease 
until after the removal of the polypus. A prolapsed 
state of the womb is very often met with in leucorrhcea, 
and may be justly suspected of maintaining an unnatural 
irritation of the mucous textures, as well as of every 
other part of the genital apparatus. The removal of such 
a prolapsion, by the appropriate remedies, permits the 
leucorrhcea to cease. 

It ought to be evident from the foregoing remarks, 
that duty to our patients, and a just regard for the suc- 
cess of our practice, urge us to demand the privilege of 
examining by the touch, the actual condition of the parts, 
in all those cases of leucorrhcea that prove somewhat 
rebellious under treatment. 

The mode of treatment should be founded upon the 
nature of the discharge, as being either acute or chronic; 
and upon the degree of constitutional disturbance already 
developed by it. The affection may exist in an indivi- 
dual so weakened and exhausted by disease as to put 
out of question the use of means adapted to lessen the 



76 LEUCORRPKEA. 

force of the general circulation. But, while I make the 
above admission, I am free to say that such a case will 
rarely be met with. There are few American physicians 
"who would hesitate to employ the lancet for the cure of 
a rebellious menorrhagia, no matter how feeble the pa- 
tient might be ; and inasmuch as the excretion of puriform 
mucus is an action depending upon excited vital force, 
quite equal in intensity to that which causes pure hemor- 
rhage, the use of the lancet appears to be as clearly indi- 
cated, as a general principle, in the one as in the other. It 
is not necessary to have a hard and bounding pulse, in order 
to warrant the use of venesection. A patient who is able 
to walk across the floor can almost always bear the loss 
of a portion of blood without great inconvenience ; and 
that inconvenience is, generally, not to be put in compa- 
rison with the invaluable influence of bleeding, upon all 
the emunctories. Bloodletting, therefore, ought to be 
more freely and commonly resorted to in the management 
of fluor albus. 

Rest, in a horizontal posture, is capable of eff'ecting 
gi'eat changes in the distribution of the blood, in the rate 
of its circulation, and in the secretions derived from it. 
Hence a recumbent position, at least, ought to be com- 
manded, and continued as long as we have reason to 
suppose that any inflammatory condition of the womb 
or vagina is maintained. The circulation becomes much 
more equable and calm, and is carried on with less effort, 
in a horizontal attitude than in any other, even leaving 
out of question the stimulating influence of the muscular 
exertions employed by those who walk or ride. 

Purging, carried to a certain extent, is a valuable adju- 
vant. The whole mucous system is connected by a 
common sympathy : impressions made on one part of it 
lessen the influence or degree of impressions made upon 
another part of the same system. The operation, there- 
fore, of a purge, which acts upon the stomach and bowels, 
is well adapted to lessen the determination of the forces 
towards the genitalia. 

A regulated diet, which tends, when properly con- 
ducted, to bring the body into the most perfect health, 
ought not to be lost sight of. It should be thoughtfully 



LEUCORRHCEA. 77 

adapted to the state of the patient, for the time being, 
and may be so adjusted as either to concur with the 
tendencies of the venesection and rest, or so as to excite 
and stimulate, if it be deemed requisite to elevate and 
quicken the vital movements. 

Cleanliness. I have been surprised to find a good 
many females not very careful of their persons, in the 
particular respect under consideration. Certainly we 
have a right to expect, that, in those who permit the 
discharges to remain upon or within the organs, an acri- 
mony will accompany the fluids excreted, that is well 
calculated to increase the amount of irritation that produces 
them. A female with leucorrhoea should use the sponge, 
with tepid water, or wine and water, several times a day. 
She who fails in the regular use of such ablutions is 
deserving, in the highest degree, of the imputation of 
filthiness. 

Injections of astringent substances into the vagina, are 
among the commonest expedients for the relief of these 
complaints ; but they will not be had recourse to by the 
prudent adviser, until by means of the remedies already 
mentioned, the irritated organs have been deprived of 
the inflammatory excitement that first gave to the mucous 
surfaces the habit of secreting in preternatural quantity. 
For the cure of ophthalmias, few men of experience can 
be found, who would employ very astringent collyria at 
the very beginning, or during the greatest height of 
inflammation, congestion and excitement ; and the same 
rule ought to be observed in our malady. 

Whenever, by means of rest, by purging, by diet, by 
strict cleanliness, and the other means already pointed 
out, we shall have succeeded in abating the symptoms of 
irritation in leucorrhceal disorders, we may with propriety 
resort to the injection of vegetable and mineral astrin- 
gents into the vagina. Decoctions of Aleppo galls, of 
rhatania root, of preparations of kino, alum, sulphate 
of copper, limewater, &c. may be had recourse to with 
good prospect of success, as abating in their use the 
bad habits of excessive secretion that the mucous organs 
had long been suffering. 

Profound sleep ought to be procured at night, under 



78 LEUCORRHCEA. 

the influence of black drop, morphia, or other conve- 
nient preparations of opium, in order not only that the 
system may recover, by repose, the vigour which results 
from sleep, but also that it maybe less susceptible of the 
irritating or enervating impressions made upon it, by a 
local disorder, in an organ endowed with so many sym- 
pathetic relations as the womb. The various balsamic 
medicines enjoy a considerable power of modifying the 
action of the mucous surfaces, and are, therefore, much 
resorted to in chronic catarrhal disorders. The balsam 
of Copaiba is perhaps the best of them, and should be 
given, after the foregoing treatment has effected a reduc- 
tion of the force of the malady, in doses of a half drachm 
or one drachm, in combination with five drops of oil of 
cubebs, and from twenty to forty drops of sweet spirits 
of nitre, at least three times a day. I do not know a 
better medium for the exhibition of so disagreeable an 
article as the copaiba balsam, than the syrup, bals. tolu- 
tan., which not only serves to correct the disagreeable 
taste of the principal article, but likewise conduces to 
the therapeutical result that is aimed at. 

Dr Dewees in this country, and Drs Forbes, Rober- 
ton, and Traill, in England, have given great credit to the 
tincture of cantharides for its power to cure fluor albus, 
after due preparation of the system for its reception. 
It may be given in doses of from ten to thirty drops, 
three or four times a day. It doubtless tends, by its 
power, so often manifested, of irritating the bladder, to 
effect a change in the action going on in the pelvic vis- 
cera generally. I am, however, of opinion that it is not 
always safe to excite so powerful an irritation, as this 
article is capable of developing, in the mucous membrane 
of the urinary organs, since those irritations are occa- 
sionally found difiicult to remove. 

Baths, either warm or cold, ought not to be neglected 
in our attempts to cure this perverse disease. The 
warm bath w411 be chiefly indicated in those cases that 
are marked by great weakness, as they occasion a more 
gentle and gradual reaction than the cold. In propor- 
tion as the patient recovers her strength, she should take 
a bath of a lower temperature, until at length, she shall 



LEUCORRHCEA. 79 

rind herself enabled to employ one quite cold, without 
inconvenience. The sea bath, at the proper season, I 
have known to prove of the greatest utility in bad cases 
of our disease. With the gradual return of health, an 
improvement of the diet ought to be allowed, with a 
little red wine at dinner, until exercise and country air 
may be looked to as the means of eradicating the last 
vestiges of the malady. 



CHAPTER IX 



PREGNANCY. 



Having now examined with such care, and minute- 
ness of detail, as were compatible with the plan of this 
book, the chiefly interesting points relative to the pelvis ; 
the organs of generation and their diseases ; the function 
of menstruation and its principal disorders ; w^e pass next, 
to the subject of Pregnancy, which is naturally ushered 
in by that of Reproduction or Generation, and leads us, 
afterwards, to enter upon the consideration of Labour 
or Parturition. 

There have appeared a great many speculations and 
theories upon the subject of Generation : yet it is true 
that, however ingenious or inventive- their authors, or 
however eloquent or argumentative in urging the adop- 
tion of their peculiar views, there still remains a terra 
incognita, which human sagacity, perseverance and toil 
have never been able to explore; and which seems pur- 
posely set beyond the reach of the utmost stretch of hu- 
man wisdom or learning. 

It must ever, we should think, remain impossible for 
man to comprehend the secret mysteries of those proxi- 
mate causes, by the force of which, a non existent, or 
formless being is drawn forth of the dark stream of time, 
and launched out on the boundless ocean of eternity; 
made partaker of a prospective immortality ; charged 
with the burthen of responsibilities to God and his fel- 
low creatures ; and bound by numerous liens to the phy- 



TREGNANCY. 81 

sical world, of which he has also become a part by the 
very fact of his entrance into a moral state. Such a 
subject, therefore, cannot fail to prove interesting to the 
medical student, whether he approaches it in view of its 
physiological connections, or whether he wishes to in- 
vestigate it as a psychological inquiry of the utmost im- 
portance in any system of moral philosophy. 

What subject indeed could be more replete with inter- 
est, than one which pretends or seeks to explain all the 
changes that are experienced by the embryo, from its 
first discoverable estate as a drop of pellucid lymph, up 
to the time when it comes forth into the world endowed 
with all the powers that are appropriate to a healthy, 
full grown foetus at term ! Such a topic involves a com- 
parison of its organs with those of the adult animal, and 
a history of their growth and development. It ought 
also to comprise an account of the accidents and diseases 
to which it is exposed or liable, and a full detail of all 
the peculiarities of the ovum and its several parts, and a 
comparison of them with the similar parts in various 
animals. The subject comprises therefore a vast field of 
physiology, which might be profitably explored by the 
curious student; but the limits of this work are too 
confined to admit of it being treated of at length on this 
occasion. The older writers made a very comprehensive 
use of the term Generation : as for example, Ambrose 
Pare, whose treatise on the " Generation of Man's Body" 
is a treatise on midwifery as it was known and taught at 
the time in which he flourished. I shall make use of 
the title of Pregnancy, on this occasion, to introduce 
such remarks as I may deem relevant on the subject of 
generation ; the nature and state of the foetus, and that of its 
adjuvant parts ; the changes that occur in the womb itself, 
and the consequences of those changes upon the woman 
who is the subject of them. 

Generation is a function of living beings : its object 
is the propagation of a race or a species : and it is eflTected 
by the union of two sexes ; for, although some organized 
beings exist, which are found to be capable of the gene- 
rative function without the conjunction of two individu- 
als ; yet in such a case there is a double sex — th'e being 



82 PREGNANCV. 

is an hermaphrodite, possessing both the male and female 
organs of generation, as, for example, the moncEcious 
plants and some zoophytes, as the common earth worm, 
the medicinal leech, &c. There are also many cryp- 
togamous beings whose modes of reproduction are not as 
yet understood ; but it appears to me not conformable 
to sound analogies, to suppose that nature has, in such 
cases, deviated from the general uniformity of her laws, 
and cast aside a principle that may be so widely traced in 
her operations for the maintenance of her organized 
species on the globe. 

It may be true that there are gemmiparous beings, in 
the true sense of that term ; and we know of many that 
are easily propagated by budding, or engrafting, or by 
cuttings ; yet these I regard as no true examples of gene- 
ration. They are rather propagations, extensions, pro- 
tractions of the same individuals. The ego, the ipsemet 
is not truly changed ; and though the stock or body 
from which the but, or graft or cutting was taken, should 
perish, it might exclaim, in the language of Virgil, JVon 
omnis moriar, pars saltern manet. Such a propagation 
is the result of art — it is an invention. I doubt not that 
some germ or seed, rendered active by a sexual orgasm, 
exists in all reproductive beings, at once the means and 
guarantee of their duration as species on the earth. 

I said generation is a function : it is not a property, 
like impenetrability, or any other property of brute mat- 
ter ; a rock or a clod does not beget sons and daugh- 
ters. Our Alleghanies have been piercing the heavens 
with their tops since ever the creation of the world ; they 
do not die, and live again in their offspring; and when 
Bonaparte told his soldiers, before one of his great bat- 
tles, " Forty centuries look down upon you this day from 
the summits of yonder pyramids," he meant to say that 
those masses of stone were the contemporaries of four 
thousand years ; but the Andes and Alleghanies are the 
contemporaries of all time ; they are yet standing as they 
have stood, unchanged, since first the fiat of the Maker 
raised them up above the clouds. How is it with man ? 
I ask not how it is with men. Men are like the morning 
cloud, and the early dew, which quickly vanish away ; 



PREGNANCY. 83 

but man, like the mountains, is the contemporary of all 
time : the globe is his dwelling-place ; and the words 
of prophecy are sure and steadfast, that when man shall 
cease to inhabit it, it will be given up a prey to that 
fervent heat which shall melt the very elements of it, 
and roll away the heavens as a scroll. Man lives on it, 
therefore, while time endures ; but he lives by a suc- 
cession of generations. He is of the trunk that God 
planted in the garden of Eden : the blood of Adam 
flows in the veins of each member of the race. 

What a subject for contemplation •! To-day the veil 
of non-existence is round about us : we issue from no- 
thing — we are fashioned and modelled, in our physical 
properties and moral attributes— endowed with faculties, 
burthened with responsibilities, and placed upon the 
platform where we play our parts : we sink again into 
the obscurity of death — our bodies become dissolved and 
enter into new combinations, while our spirits fly to 
unknown regions, bearing with them all that is noble 
and enduring of the work of our Maker in us. What 
an extraordinary scene ! Eight hundred millions of us 
in all ; and twenty millions, at least, who come upon 
the stage like shadows, and so depart, every year. Men 
are but the bond of union betwixt the earliest and latest 
generations of the race of man. If, as has been eloquently 
said, the springing up of a blade of grass from the bosom 
of the earth is calculated to fill the mind with wonder and 
amazement ; what far more vivid impressions of the mi- 
racles of nature, are likely to be made upon those, who 
contemplate the unfolding of those organs and faculties, 
by means of which, man learns not only to know and 
acknowledge his Maker, but to render himself, as it were, 
a still more fitting image of him, by the cultivation of 
the powers that have justly given him the title of the lord 
of creation ! 

Sensible as we are of the darkness and doubt that in- 
volve this subject, we feel bound to give it a place here ; 
and shall proceed, therefore, to state very briefly, that there 
are three principal theories of reproduction: of which the 
1st contends that the foetus is constituted of a mix- 
ture of particles, or molecules, derived from both the 



84 PREGNANCY. 

father and the mother ; the 2cl, that it is derived wholly 
from the father ; the 3d, that it is derived wholly from 
the mother. 

William Harvey, the celebrated discoverer of the cir- 
culation of the blood, had published, about the middle of 
the seventeenth century, the doctrine that all animated 
beings are derived from ova or eggs ; but it was not until 
1670, that Regnier de Graaf asserted that the female 
ovaria were not testes foemininae, but that they were real 
ovaries or egg bags, and that the transparent vesicles 
within them were ova. It was from him that the ovaria 
derived their present name. 

The substitution of the doctrine of ova, or the develop- 
ment of pre-existent germs, for that which had long 
reigned in the schools, and which supposed a real gene- 
ration to take place, greatly changed the philosophy of 
this subject, for it had for ages been supposed that the 
embryo " duplicide semine constat," to use the language 
of Lucretius ; and that the new being resulted from the 
action of a.for7native poiver, upon a material or substance 
subjected to its plastic forces. 

Yet, even supposing that the mother does furnish a 
semen fcemininum, it was asked, Can the conjunction 
and adventitious mixture of two liquids, consisting each 
of a few drops of mucus, result in the formation of a 
living, moving, sentient being ? Does not the analogy of 
the seeds of plants, the eggs of birds, and the spawn of 
fishes, fully show that the primordia, the rudiments of their 
respective kinds, exist, without exception, in a germ more 
or less perfect, according to the nature of the plant, bird, 
fish, &c.; and will nature, who provides the beginnings of 
her creations, by establishing the faint lineaments of their 
organization, in seeds, eggs, &c. — will she depart from 
her known simplicity and economy of means, in the case 
of man and the mammalia in general ? On the contrary, 
nature, Avho is always consistent, establishes the bud, the 
germ of our existence, before we really begin to exist. 
The doctrine of Lucretius is no longer tenable ; the 
docrine of " duplici de semine constat" is not true; 
but that of '' omnia ex ovis" is true. 

This doctrine did not enjoy an undivided reign very 



PREGNANCY. 85 

long. The curious researches of philosophers soon 
enabled them to discover in the prolific fluid of the male, 
a great number of little animals, or rather animalcules ; 
and then they asserted that the ovists were in the wrong, 
for these little seminal worms were assuredly the ger- 
mina of human beings, and thus there was a new doc- 
trine — of spermatic animalcules. So that we have now 
under revision three hypotheses : 

1. That of the union of two seminal fluids. 

2. That of Ova. 

S. That of Animalcules. 

Let us now return to the first : the doctrine of the 
union of particles from both parents. I shall state what 
was thought by Buffbn and Blumenbach ; for it is not 
worth while to go further back than this. 

The illustrious Count de Buffbn admits the Graafian 
vesicles, but says they are not eggs, not ova ; they are 
only reservoirs of female semen, which flows out of them 
by means of the funnel-shaped mouth of the Fallopian 
tube ; and passing through the Fallopian tube falls into 
the womb, and is there commingled with the seminal fluid 
injected by the male. 

He says that, common, brute, or dead matter has only 
physical properties ; it cannot grow nor germinate — it is 
subject to physical laws and impulses only. Brute or 
dead matter, and vital or living organic matter cannot be, 
therefore, one and the same. No : there really exist in this 
world a vast number of little organic molecules or enti- 
ties — entia — beings. The air, the earth, the waters are 
full of them. The world is a huge magazine of them, 
and they are common to the vegetable and animal king- 
doms. Vegetables and animals appropriate them for the 
purposes of growth and support. They are primitive, 
incorruptible and unchangeable ; and their assemblage 
and conjunction under certain forms, constitute the vari- 
ous beings that exist on the globe. A given number and 
arrangement of these molecules make a man, a horse, or 
any other animal, according to their construction. Ge- 
neration and growth, therefore, are only changes of 
form and arrangement and aggregation of these vital, 
molecular entities ; while, on the other hand, disorgani- 

H 



86 PREGNANCY. 

zation and death mean the disaggregation and removal of 
these deathless monads. If I have been happy enough 
to explain myself clearly thus far, the reader will have 
no difficulty in understanding how this philosophy is 
applicable to the theory of generation. These molecules 
which are floating about in the world are disposed to 
occupy certain places in the creatures whose bodies 
they assist to compose ; indeed they are a sort of idea of 
the organs which they help to constitute ; for example, 
there are nose particles and ear particles and finger 
particles, which cannot become toe particles or knee 
particles, or molecules of the heel. They have a sort of 
constitutional habitude or aptitude for certain forms, but 
not for all forms. Every living being, whether man or 
cabbage, hippopotamus or tadpole, is composed wholly 
of organic molecules, equally capable of giving physical 
expression or form, as the inorganic molecules that com- 
pose the mountains and strata of the earth. 

To proceed. The foetus in utero grows daily in size, 
by adding molecule to molecule ; its term of utero-ges- 
tation is completed ; after its birth, the child still appro- 
priates molecule after molecule, out of the inexhaustible 
magazine of nature. It arrives at the estate of manhood. 
Whatever it has been hitherto enabled to hoard up has 
been employed in strengthening it and bringing it to 
perfection. It has, hitherto, had none to spare — it has 
acquired no more than are necessary for its existence. 
But when it has attained to manhood, and the powers 
and habits of self appropriation are completely esta- 
blished, by long use and custom, it no longer grows, and 
therefore collects more molecules than are needful for 
mere nutrition. The arm, the head, the leg receives 
more than it wants ; hence, as the vital molecules have a 
constant tendency to assume organic forms, they shoot 
out, as the beard, the whiskers, the hair of the body, 
the female mamma : hence, too, the beautiful rotundity 
and plumpness of the female form, at that lovely period 
of the teens ; and hence the menstrual flux, which is but 
an overflow of the superabundant vitality. Hence, also, 
the new secretion of the male testis, and the turgid state 



PREGNANCY. 87 

of the Graafian vesicle, which is filled with organic 
molecules. 

In his view of the subject, both the fluid of the vesicle, 
and the semen are to be regarded as extracts, a sort of 
inspissated molecules of the whole body; these extracts 
being composed of organic particles, which have an inde- 
feasible tendency to organize, to set up a constitution. 
They come to the testicle and ovary from every part of 
the male and female body. No portion of the machine, 
no tissue, membrane or ligament is without its repre- 
sentative in this cour jileniere of vitality. Liver, heart, 
membranes are all here, but in chaos, in confusion. The 
great point is, that they have a tendency to reunite ac- 
cording to their ancient constitution ; and they only wait 
for a favourable situation and a certain impulse, in order 
to re-arrange themselves in one form and place, as in the 
ancient regime, and as their archetype father had done 
when he was but a mass of trembling jelly. Thus, by 
a plastic virtue of the two semens, under orgasm, the 
embryo form is gradually unfolded, and runs the same 
race its parent had run before it. The male and female 
semen are united in this constructive act ; hence arises 
the similitude to both parents, or the predominant resem- 
blance to one or the other, like the families of Dentatus 
and Rufinus of ancient Rome — like the Bourbon noses 
and Hapsburg lips of more modern days. One seminal 
fluid could not germinate ; it must be mingled with that of 
the other sex, and must derive from the venereal orgasm 
an impulse, a sort of augmented vital force or excitement. 
To use an American phraseology, which though not 
elegant is expressive — it must get a start. 

Such is the theory of Buffon. I hope the reader may 
understand it from our statement— but not believe it. It 
is a pretty philosophical romance ; and argued so elo- 
quently and ingeniously in the first volume of his His- 
tory of Animals, that I trust every student will take an 
opportunity of studying it out at length. It will well 
reward his pains, by the exquisite beauty of the style, 
and the rich stores of facts which he has collected for its 
sustentation. 

I suppose that a dozen arguments against the Buffo- 



88 PREGNANCY. 

nian ttieory, of the mixture of particles from both parents 
in generation, have presented themselves to the mind of 
the reader already : as first, the ovarium does not secrete 
any semen foemineum — it is not a testis, but an ovary ; 
and second, an animal that has lost any one of its parts, as 
a limb for example, is not, on that account, incapable of 
procreating a perfect offspring — but if so, whence are the 
monads of the offspring derived, since the parent had 
lost them ? 

Let us leave the Buffonian doctrine here, and now 
inquire what is meant by Blumenbach's Nisus Forma- 
tivus, for Professor Blumenbach holds the old opinion of 
Lucretius, the "duplici de semine constat/' 

The favourers of the doctrine of ova entertain the opi- 
nion of pre-existing germs, as I am about to explain ; but 
Professor Blumenbach regards the idea of pre-existing 
germs as repugnant to reason — as implying a superfluous 
and useless creation of innumerable entia, that can never 
arrive at perfection : for as one pair are sufScient to 
people the whole earth with their offspring, the death of 
that pair involves, of course, the blight of so many germs 
as might serve to fill and populate the globe for an un- 
limited succession of ages. 

Hence he prefers the doctrine of Epigenesis, or what 
he denominates the Nisus Formativus, by which a real, 
but gradual formation of an embryo out of the before 
formless genital matter is brought about. 

" Vital powers," says Professor B. " exert their pe- 
culiar influence on the matter of organized bodies. That 
vital power which, acting on organic matter hitherto 
shapeless but mature, imparts to it a form, regular and 
symmetric, but varying according to the nature of the 
matter in subjection, is distinguished from all other kinds 
of vital force, by its ability to produce form, construction, 
arrangement, constitution, organization, or whatever 
such term may best explain my meaning. There are 
digestive powers, nutritive powers, secerning powers 
[this is a formative power, he calls it ' nisus formativus']]. 
When mature genital matter is properly placed in the 
uterus, the nisus formativus begins to operate ; lays in 
it the rudiments of a conception, and gradually evolves 



PREGNANCY. 89 

its organs, preserves them such during life, and repro- 
duces or restores them when lost or mutilated by dis- 
eases or accidents. 

" Some time is required to enable the seminal liquors 
to become intimately blended. When that is effected, the 
nisus formativus converts them partly into the embryo, 
partly into its membranes, and partly into the placenta ; 
hence several days always elapse before the product of 
conception is formed or observed in the cavity of the 
womb. 

"The advocates of * germs,' " says M. B. "must 
resort at last to a nisus formativus to explain the devel- 
opment of those germina, which, without the interference 
of the generative act, would remain for ever in the state 
of germs, and never arrive even at the embryo state." 

In the above extract, I find it difficult to comprehend 
what M. B. means by " an organic matter hitherto shape- 
less but mature." That great philosopher, by seeming 
to require a sort of maturity of the material upon which 
his vital power is to be exerted, in order to the formation 
of an embryo, does virtually admit an antecedent state of 
preparation of the material, which differs more in name 
than in truth from the opinion which contends for pre- 
existent germs. A germ is but the material in a state of 
preparation ; and the shapeless but mature matter of M. 
B. is the same thing. This may serve to show the dif- 
ficulties that surround this subject ; since M. B. has 
found himself compelled to admit an antecedent state of 
preparation or maturity of the matter of the embryo, in 
order to avoid the alternative, of admitting a real and 
direct creation by means of the reproductive power. 

These remarks are all that I have thought needful to 
offer the reader concerning the doctrine of the double 
semen : let us now take up that of the animalculists. 

There was a young physician who formerly lived at 
Dantzig, from whence he went to study medicine at 
Leyden, in the year 1677 ; his name was Lewis Hamme, 
or Hammen. About that time every body was engaged 
in microscopic observations, for it was the rage of the 
day, and this young Lewis Hamme was as fond of his 
lens as any modern pathologist of the dissecting knife. 



90 PREGNANCY. 

Among other curious objects of research he took it into his 
head one day to examine the semen mascuHnum through 
his lens, and found it full of little animalcules, like vin- 
egar eels or tadpoles, and was so very much pleased 
with his discovery that he went to Delft, where Anthony 
Leewenhoeck lived, and not only told him what he had 
found, but actually showed them to that gentleman. 
He was well served for his pains, as he was fairly 
deprived of all the credit, if credit there could be, of first 
inventor; for Leewenhoeck, who had heard all about De 
Graaf's ova, soon found that with these very small 
monads he could make a very great noise in the world; 
and so it proved. 

This person was born at Delft, in Holland, in 1632, 
and acquired a very great reputation all over Europe, by 
the admirable microscopes he constructed, and the extra- 
ordinary discoveries he made with them. He pushed his 
researches on the seminal animalcules to an almost in- 
credible extent. He describes them as having a head 
and tail similar to those of the tadpole. They are ex- 
tremely active, always in motion, moving their tails like 
a snake ; approaching each other, and even uniting in 
a sexual embrace. He thought there were male and 
female monads, and that the difference of the sex was 
pointed out by the form of the tail. They were very 
small ; so very small indeed, that fifty thousand of them 
were quite comfortable in a drop of semen no bigger 
than a grain of sand. They exist in the semen of 
all animals, from man down to a louse. There are 
more animalcules in the semen of a single millipede, 
than there are men, women and children on the whole 
globe, although these are computed to amount to eight 
hundred millions. 

Like many other philosophers, Anthony Leewenhoeck 
taught that no sentient, moving being could be consti- 
tuted out of mere inorganic molecules ; which, as they 
are inert, brute and dead, cannot become alive, sentient 
and active ; and therefore he insisted that the germs of 
such creatures must pre-exist. He would not admit the 
Graafian vesicle as the germ, but asserted that his ani- 
malcules are the rudiments of the foetus, which being 



PREGNANCY. 91 

injected into the maternal organs, had nothing further to 
do than grow and be born in due time. 

Hartsoecker and Valisneri also made painfully minute 
examinations of these little creatures. Hartsoecker quar- 
relled with Leewenhoeck about the date of discovery, 
asserting that he had seen them first ; but he is com- 
monly supposed to have made an unfounded and unjust 
claim in this case. He could not only see them very 
clearly, but he traced their resemblance to the human 
form. He found that they would stick their tails into 
the ovarian vesicles, and, like so many weasels, suck 
them dry. 

Valisneri saw them also very clearly : speaking of 
them in the semen of a rabbit, he says, *' e gli ricon- 
nobi, e gli giudicai senza dubitamento alcuno, per veri, 
verissimi, acchiverissimi vermi." 

It is surprising what a run this doctrine of spermatic 
worms had, and, notwithstanding the occult nature of 
the research, what various classes of persons engaged in 
it, assuredly without any other prospect than that of 
either gratifying a prurient curiosity, or discovering a 
useless truth. Dr EUiotson, in a note in his edition of 
Blumenbach's Physiology, portrays in the strongest 
terms the extraordinary scene of curious inquirers into 
these arcana of nature : his statements show how the 
power of imagination is capable of misleading the judg- 
ment, even in matters relating to natural history. Da- 
lempatius is said actually to have seen a seminal animal- 
cule assume the form of a human being. Even the 
august monarch of England, Charles H., was engaged 
in the microscopic observation of these animalculae ; an 
additional proof, if any were wanting, of the profligacy 
of that king. Dr EUiotson says, that " Physiologists, 
naturalists, popish priests, painters, opticians, and book- 
sellers, all eagerly joined in the pursuit," &c. But 
what has been the result of all the noise made in the 
world upon so unworthy a subject, which, evidently, 
never could have been deemed really worthy of inves- 
tigation. No solid good has arisen from it, and we 
may agree with Dr EUiotson, who says, " Sure, never 
were so much folly and beastiality before committed, 
(h) 



92 PREGNANCY. 

under the name of philosophy." — ElliotsorCs Blumen- 
bach, p. 290. 

When Leewenhoeck was asked how he could recon- 
cile it to the order of nature, that so many millions of 
animalcules should be formed to waste, since only one 
could become a man, he replied that the fact is exactly 
conformable to the order of nature, who prepares my- 
riads of seeds that never grow, but are wholly lost and 
destroyed. And further ; as there is only a very minute 
pore in the Graafian vesicle, into which a spermatic 
worm must find its way, there would be a million 
chances to one against its ever reaching that hole, if there 
were only one animalcule in each ejection of semen ; 
but if there be a million of them, there is an even chance 
that at least one will find the opening. 

A spermatic animalcule, therefore, according to Lee- 
wenhoeck, gets ensconced inside of an ovarian vesicle, 
and there grows. 

It is now evident that this doctrine of spermatic germs 
is susceptible of being carried so far as to imply the 
existence of germs in a series mounting up to the origi- 
nal creation, and descending to the very end of time. 
If a man cannot produce or create the germ of his son, 
but must have him pre-existing in his body, a fortiori 
that germ will be unable, and so on ad infinitum for- 
wards, and backwards to the very genesis. 

We now come to the third and last opinion, that of 
Harvey, De Graaf, Spallanzani, Bonet, Haller, and others. 
This opinion holds that the child is derived wholly from 
the mother, and not from the father. The chief original 
defender of this doctrine was the great English physi- 
ologist William Harvey. He made a great number of 
experiments, which are related in his work on Genera- 
tion. The results of these confirmed in him the belief 
that all animals are derived from ova, which are more or 
less perfect, being most so in birds. 

The semen of the male is regarded, in his view, as 
only the stimulus which provokes the ovum to com- 
mence its growth, and not as furnishing any particle 
of matter to tlie constitution of the new animal. He 
never observed the changes that occur in the ovary, 



PREGNANCY. 93 

and did not, therefore, suspect the ovarian vesicle to be 
the seat of the animal germ. This was shown to be the 
case at a later period; but as he had often seen the 
beginnings of a conception in the uteri of animals he 
examined and as he had noticed the similarity of that 
ovum to the eggs of birds, he took it for granted that it 
was an egg, and declared that all beings are derived 
from ova. 

This is the doctrine which is denominated more pro- 
perly Evolution, and which has been carried to a great 
length by Haller, Bonet, Spallanzani, &c. 

The same Regnier de Graaf whom I have already- 
mentioned several times, was the first to find that the 
generative processes were attended with certain changes 
in the ovaries ; that the small vesicles contained in them 
assumed a yellowish colour; and as he, on a careful 
search soon after copulation, several times found some 
of those bodies in the Fallopian tubes of the animals on 
which his experiments were made, he concluded they 
were eggs passing down through those oviducts to the 
womb, in order to undergo in that organ their full and 
final development. Nicholas Steno, Svvammcrdam, 
and Van Horn assert that they all saw them before De 
Graaf. 

A different question now presented itself. Suppose 
that man, and all animals and vegetables are really de- 
rived from ova ; are we to conceive of these ova as pro- 
duced by a mere epigenesis, a begetting or formation of 
an animal upon and from the matter of another animal ? 
Does the new animal's existence date from the mo- 
ment of conception, or did its faint but real lineaments 
exist previously to that act of conception in the germ, as 
it lay concealed in the maternal ovary ? How can a 
new, living, sentient being issue from the apposition of 
mere material molecules, confused and amorphous ? Can 
dead matter beget living ? It is as well to say at once 
that all generation is equivocal — that animal forms and 
properties may evolve themselves from fortuitous combi- 
nations of matter. That is very difficult to believe. Such 
a combination would be as apt to result in the production 
of a lion or an ape, as of a human being; but we find that 



94 PREGNANCY. 

women bring forth human children, cows bring forth 
calves and not colts. There must be therefore — there 
is — some predetermined form, some mould, in which the 
new animal will be cast, and its elements arrange them- 
selves. The germ must have existed as long as the 
mother who bore it ; since her organs are manifestly 
incapable of secreting a perfect and complicated creature 
made up of such vast variety of tissues and organs. 

Going thus far, we are compelled to go still further, 
and to admit that if the mother is incapable of forming 
the germ, that germ is, a fortiori, incapable of the same 
creative act ; and so we mount upwards to the original 
creation, when all the germs that are now, or have been, 
or shall hereafter be in existence, were delivered, com- 
plete in all their essential attributes, out of the hands of 
the Creator of the universe. 

Passing by the consideration of the minor authorities 
upon this strange topic, I shall proceed to lay before the 
reader the sentiments of the ingenious Spallanzani ; 
whose experiments upon impregnation so far outstripped, 
for curious research, indefatigable patience and scrupu- 
lous accuracy, all that had been previously attempted 
upon this subject, that he justly stands at the head of 
this department of obstetric physiology. 

Spallanzani's work is entitled. Experiences pour 
servir a I'Histoire de la Generation des Animaux et des 
Plantes, and was edited by John Sennebier, Minister 
of the Holy Gospel, and Librarian to the Republic of 
Geneva. Geneva, 1785. 

These experiments were made on frogs, toads and 
salamanders. These animals (the females) have ovaria*, 
and a uterus. The ovaria are replete with eggs, which are 
easily discovered on opening a female frog. If the ani- 
mal be examined early after the sexual intercourse has 
commenced, the eggs or ova will be found in the ovaries ; 
if at a later period, some will be found to have passed down 
the oviducts to the uterus. In the sexual act, the male 
places himself on the back of the female, and embraces 
her with his fore feet under the axillae, so firmly as to 
hold on while she hops from place to place, and some- 
times to kill her by the violence with which he presses 



PREGNANCY. 95 

her sides. He has no penis ; but he is possessed of a 
small organ which protrudes a little, and from which 
issues a seminal fluid, that does not enter the organ of 
the female, but only bedews or is sprinkled upon the 
string of ova, as they issue from her body. 

Eggs which are touched by this fluid are found to be 
fecundated, and if deposited in proper places, become 
tadpoles, which are soon after changed into frogs. Those 
eggs, however, which pass out of the female's body 
while the frog is prevented from sprinkling them with 
his semen, are not fecundated, but they soon putrefy and 
are wholly lost, or blasted. 

Spallanzani often opened the female frog and took out 
of her uterus the unimpregnated ova ; but they always 
perished, no matter how carefully he managed them, 
unless he sprinkled them with the frog's semen. 

He managed to collect the semen from the male frogs, 
and with a fine brush dipped in it, put it upon the ova : 
all such ova were as eflectually fecundated as if it had 
been done by the male animal itself; and in this manner 
ample opportunity was gained of testing the powers of 
that secretion. 

If unfecundated ova were put into a vessel of water 
without having the brush applied to them, no tadpoles 
were hatched; but if a part of the same string of ova 
were put into another vase, the brush being previously 
applied, Spallanzani had soon a large brood of young 
tadpoles. 

By carefully observing these frog's eggs with glasses, 
and watching their progress, he afterwards found that they 
were not really eggs, but really tadpoles packed up in a 
globular form, and capable, after fecundation, of burst- 
ing the sort of amniotic membrane in which they were 
enclosed. Those within the body, and before fecunda- 
tion, were exactly like those out of the body shortly 
after the male semen had been applied, or after they had 
been fecundated ; with the sole exception, that they would 
not grow and hatch. 

What do these experiments prove, if the tadpole is 
really formed before it descends into the uterus, and only 
receives the aspersion from the male after it leaves the 



96 PREGNANCY. 

mother ? Do they not prove that the mother is the 
source whence they are wholly derived, and that the 
father only performs a subsidiary act in the matter? 

Do they not prove that the germ of the fcEtus existed 
before the father had any thing to do with the begetting 
of the tadpoles ? Unquestionably they do. 

Lest any one should suspect, after all this, that the 
spermatic animalcules might some how get into the ova 
and there become tadpoles, Spallanzani declares that he 
used the semen after in vain carefully looking in it for 
animalcules with a microscope. There were no worms 
in it at all, and nevertheless it was prolific ; so that the 
idea of spermatic worms being necessary to render the 
semen prolific, is wholly refuted. 

He used the greatest care in excluding the animalcules 
from the semen he wished to employ ; he even mixed 
wine and vinegar with the liquid, but it fecundated the ova 
nevertheless. He put a few grains into eighteen ounces 
of water ; a drop of this weak solution was nevertheless 
effectual; and even old semen, collected from the seminal 
vesicles some time after death, was also efficient. 

The experiments of Spallanzani were thought so com- 
plete and decisive, as to establish the doctrine of a pre- 
existent germ, which was only evolved by the act of 
generation. 

If you open a hen's egg and separate the yelk from 
the white, you will find on the surface of the yelk a 
small spot called the cicatricula. This small white spot 
exists in the eggs of pullets that have never admitted the 
male bird : a pullet's egg is an unfecundated egg. Well ! 
this cicatricula, in a fecundated egg, begins to grow very 
soon after the warmth of the incubating hen has pene- 
trated all parts of it; a vascular circle soon forms round it 
on the membrane of the yelk, and increases until the chick 
is completely formed. Before the chick leavers its shell, 
the yelk that remains, with its membrane, is taken up 
into the body of the young and serves to nourish it. It 
is proved that the membrane of the yelk is continuous 
with one of the young bird's intestines, and that the yelk 
is carried through it into the bowel, there to be acted 
upon by the digestive powers. 



PREGNANCY. 97 

Now as this yelk, and this membrane which is conti- 
nuous with the organs of the chick, exist before fecun- 
dation, are we not clearly warranted in believing that 
the lineaments of the embryo actually exist within the 
egg anterior to and independent of the male ? 

Such is the opinion of all those who assert that germs 
pre-exist in the female, and that the sexual union does 
not bring it into existence, but only excites it — gives it 
propensity and power to grow. 

There is a small insect called in French puceron, or 
vine-fretter, which has afforded a singular argument in 
favour of the doctrine of pre-existing germs. This insect 
is propagated by a generative union of the sexes ; but it 
is found that a female once impregnated, or having her 
ova fecundated, will at the same time have her posterity 
fecundated for nine generations : that is, her children 
will not require the approach of the male, nor her chil- 
dren's children to the ninth in lineal descent ; after that, 
however, the male must be admitted in order to fecun- 
date anew. What answer shall we make to tMs argu- 
ment, or rather this fact, if it be one ? Does it irrefra- 
gably prove that nine generations were boxed up one 
within another, and that the whole series of eggs were 
fecundated by a single copulative act ? 

But what is the use of supposing a pre-existent germ ? 
This is the use. It is thought to obviate the difficulty 
arising from the circumstance that mere matter cannot 
create an organized body ; that there must be some 
creative or impulsive power — some bud, seed, or germ 
derived from the hand of God himself; and hence the 
incredible theory has been published ' and supported 
by elaborate writings, that the whole human family, all the 
mammalia, birds, fishes, insects, plants, whatever lives or 
has being on our globe, was originally encased within 
the ovarium of an original mother of each species ; and 
that each undeveloped ovum or seed — among the count- 
less multitudes of the wheat and grass fields, the innu- 
merable spawn of fishes, and incalculable variety of 
insects — was not only created at the original creation, 
but that each one of these contains, in this nineteenth 
century, germs enough to supply the globe again and 



98 PREGNANCY. 

again, if their several species could become extinct and 
lost save one pair. A plant that is crushed under the feet 
of an ox, an egg that is broken, a child that dies in infancy, 
a human abortion, involve, therefore, the destruction of 
innumerable entities, which God has created only to per- 
mit them to be destroyed. Does this sentiment comport 
with that tender care which is over all his works ? Is it 
reverential to God to accuse him of sporting thus with 
his creative power, and using his foreknowledge, his 
benevolence and his wisdom without object, aim or end ? 

It is pretended that the use of this doctrine, as I said 
just now, is to explain the origin of organic bodies. But 
does it explain that difficulty ? No ; it only removes it one 
step off, and presents a greater. Besides, if, as we often 
see is the case — if nature is capable of reproducing organic 
parts of animals, there is no greater exercise of power 
required for reproducing all the organic parts of an 
animal. A lobster, that loses its claw, is not long in 
reproducing a claw provided with the same muscles, 
absorbents and tissues as were in the original member. 
Here, then, by a sort of extension or real propagation of 
the constructive power, a nisus formativus, in short, a 
new organic part is composed. Wherefore, may we not 
suppose that the same power in the female organs may, 
by its simple extension or propagation, lay the foun- 
dations of a brain, a heart, an alimentary canal, and 
indeed a whole body ? If it be said, in objection, that 
the lobster's claw grows from a germ, I must decline 
admitting the objection, inasmuch as the model of the 
claw being lost, there remains no germ, no mould, no 
predetermined form by which its growth could be 
fashioned, or its dimensions limited and restrained. A 
biceps muscle is no mould or germ for a pronator qua- 
dratus, nor is a triceps the model of a palmaris. 

The doctrine of the evolution of pre-existing germs, 
encased or emboitees one within another, does not re- 
move any one difficulty. Does it explain the difference 
of sexes ? Can we reconcile it with the resemblance of 
children to their parents, in physical form and propensi- 
ties, or in intellectual and moral character ? Why should 
a black man beget a woolly -headed fcetus upon the ovule 



PREGNANCY. 99 

of a white female ? or -why should a mule hybrid be 
the result of the union of the ass and the horse ? If the 
germ were white, how does it acquire the black rete 
mucosuiii ? or how, in the second case mentioned, shall 
we explain the imperfect development of the genital 
organs ? If they are really formed upon a mould pre- 
existent and derived from the hand of the Creator at the 
origin of the world, why does it deviate, and yield a 
result which tiiat Creator had not intended or foreseen? 

Let us now recapitulate. 

The ancients believed that the seminal liquors of the 
male and female united in the womb, are gradually con- 
verted into the living organized embryo. 

Leewenhoeck taught that the spermatic worms, or 
seminal animalcules, are the germina of men, women, 
birds, beasts and creeping things. 

Spallanzani and Bonet tell us that we are all six 
thousand years old, having been packed up from the 
beginning of time, like so many pill boxes or crucibles, 
one within another. 

Buffon, as I have already said, considered the world 
to be replete with organic particles, &c. 

There are many living philosophers, and innumera- 
ble dead ones, who have supposed that all nature is filled 
with vital organic molecules or particles, which require 
only certain accessory circumstances to enable them to 
germinate and coalesce with the organic forms of animated 
beings. On the subject of generation these are neither evo- 
lutionists norepigenesists ; they are panspermians ; their 
doctrine is called panspermy. Blumenbach is not a 
panspermian ; Buffon is. 1 do not know whether any 
of my readers are likely to take up that faith. If they 
think, with me, mere matter is brute, dead, inert; if they 
think that a plant may exist on distilled water composed 
of oxygen and hydrogen, and that it can absorb its car- 
bon from the air, and procure its other chemical consti- 
tuents somehow else : they will think also that that 
plant can convert dead matter to living, and then become 
food for man. 

All flesh is grass, and all grass can make its vital 
particles for its own use ; it does not find them ready at 



100 PREGNANCY. 

hand. / reject the panspermy ; I profess to have no 
fixed notions on the subject of reproduction, which, like 
other vital forces, possesses a sort of metaphysical sub- 
tlety which is too subtle for the comprehension of finite 
minds. I have thought it needful, however, to say 
what I have already said, as it is a part and parcel of the 
subject of Midwifery, and has a just claim to constitute 
a portion of every general sketch of that branch of medi- 
cal contemplations. 



The Germ existing in the ovarium, and which has 
already been spoken of under the title of the Ovarian, 
or Graafian vesicle, becomes fecundated, as the first act 
in the series of changes that occur in Pregnancy. 

In consequence of the fecundation of a germ, it is 
removed, by unknown processes, from its gangue in the 
ovary, and conducted along the canal of the Fallopian 
tube into the cavity of the womb. It is, like a seed, 
removed from its native pericarp, and planted in a fa- 
vourable soil, where its new growth is to commence, 
and continue until the attainment of all the qualities 
requisite for its independent existence. 

The fecundated ovule is, in one sense, an independent 
organ. It imbibes, from the vital surfaces with which it 
is in communication, the elements of its augmentation, 
and makes rapid progress in growth and vigour. 

At the time the act of fecundation takes place, or soon 
afterwards, the inner surface of the womb undergoes a 
change, which causes it to be covered with a deposit of 
plastic lymph, or albuminous matter, which adheres to 
every part of the inner paries. This deposit has been 
likened to a coat of white paint plastered over the mu- 
cous lining. It might be better compared to the inflam- 
matory exudation of croup, or to those white crusts that 
are found to line the soft palate and arches in some angi- 
nas. Be this as it may, when the small Graafian vesicle 
reaches the uterine extremity of the Fallopian tube, it 
finds the orifice closed by this material, which it pushes 
away as it advances, and at length gets within the ute- 



PREGNANCY. 101 

rine cavity ; one of its hemispheres resting in contact with 
the naked surface of the womb, while the other is still 
resisted by the new deposit which it had thrust away 
before it as it came into the cavity : it is thus placed 
betwixt the womb and the deposit. As this new deposit 
is a mere exudation, intended to subserve only temporary 
purposes, and to be discharged when those purposes have 
l3een fulfilled, it is properly called the deciduous coat, or 
caducous coat. But the ovule thrusts the caduca away 
before it, turns it back, reflects it ; and, on that account, 
the deeidua has two appellations : 1. Decidua vera, mean- 
ing all that part that remains in contact with the womb } 
and 2. Decidua reflexa, or all that part which is reflected 
or pushed away by the advancing ovule. When the 
ovule arrives, it is not so big as a pea ; but the cavity of 
the womb is much greater. The decidua reflexa, which 
closely covers the ovule, is just large enough to cover 
it or enclose it ; but the decidua vera is as large as the 
whole uterine cavity. In process of time the ovule is 
found to have grown large enough to fill up the whole 
cavity of the womb ; and as it always carries the re- 
flected part of the decidua with it, it follows that the 
decidua reflexa and the decidua vera come, at last, to be 
brought into close contact, and by the continued pressure 
of the womb, are finally so united or fused together, as to 
be inseparable and indistinguishable from each other. 

While the decidua reflexa is thus rapidly increasing 
in size, pari passu with the enlargement of the ovum, 
the space betwixt the two deciduae is not void ; it is 
filled with a substance resembling white of egg^ con- 
tained in a delicate hyaloid membranous network. This 
substance entirely disappears before the fifth month of 
gestation. It is scarcely necessary to repeat here, 
that as the uterine surface is covered with decidua, 
menstruation does not take place, and that there is a 
suspension of that function during a pregnancy. 

The ovule, upon entering the uterine cavity, consists 
of an outer membrane, the chorion, which encloses the 
inner membrane called the amnion, within which is 
the liquor amnii, and the embryo, connected with the 
amnion by its cord, or navel string. For the most part 



102 PREGNANCY. 

the o\Tile attaches itself to the naked surface of the womb 
in the vicinity of the orifice of the Fallopian tube through 
which it entered : but it certainly does, in a good many 
instances, move to the fundus, or to the anterior, or the 
posterior surface of the organ ; or it may even fall down- 
wards into the vicinity of the upper opening of the cer- 
vix, and attach itself there ; but wherever it happens to 
fix itself, there is the seat of the placenta, and from that 
point does the decidua reflexa begin to encroach upon 
the cavity of the decidua vera. 

It is asserted by some, and denied by other writers, 
that the outer membrane is covered wit?i villi from the 
first moment of its arrival in the uterine cavity. With- 
out attempting to settle this question, for which I am by 
no means prepared, it is sufficient to state, that at the 
end of the fourth or sixth week, the entire surface of the 
chorion is furnished with numerous villi or spongioles, 
and that these villi are the means by which the ovule 
attaches itself to the living surface, and that they ulti- 
mately are converted into a placenta. The placenta is, 
therefore, a production of the chorion. It comes ofl* 
with the chorion, and is utterly inseparable from it ex- 
cept by rupture. No part of it is supplied by the womb. 
When the ovum is expelled, whether by abortion, by 
premature labour, or at full term, the placenta is sepa- 
rated from that organ, and leaves nothing adherent to it. 
It is simply set upon the surface, and may be at any 
time peeled oiT without the slightest difficulty. The 
skin of a ripe orange does not peel from the fruit more 
easily than the placenta from the womb, at all periods 
of gestation. 

Admitting that those villi of the chorion that are in 
contact with the naked surface of the womb, are finally 
converted into placenta ; then the whole of the villi that 
are in contact with the decidua reflexa never form any 
union with that substance ; the necessity for their exis- 
tence ceases, and they slowly disappear, until the chorion, 
where they covered it, becomes a smooth shining mem- 
brane. I have seen several specimens of the ovum dis- 
charged whole at three and at four months; and in such 
cases I have always found the placental part of the chorion 



PREGNANCY. 103 

strongly expressed, while the remainder of the membrane 
resembled an egg from which the shell had been carefully 
removed, or one on which the shell is not yet deposited. 

M. Velpeau remarks that the portion of the spongy 
surface of the chorion which continues in contact with 
the living surface of the uterus, becomes the seat of a 
very active nutrition ; the spongioles enlarge, and among 
them soon appear the blood vessels which are shot 
forth by the umbilical vessels of the child. It seems 
now to be generally agreed that the spongioles of the 
chorion are not blood vessels, but merely a sort of areolae, 
subserving the purposes of nutritive absorption, up to 
the period when the forces of the embryo acquire a cer- 
tain degree of development. 

Inside of the chorion is found the membrane denomi- 
nated the amnion. It is not, in the early stages of preg- 
nancy, near so large as the chorion, which, indeed, it 
touches only at one point. There is found betwixt the 
two membranes a sort of vitreous humour, or fluid, con- 
tained in a delicate network, which is gradually removed, 
by some unknown process, as the amnion becomes 
larger, until at length, when it (the amnion) becomes 
large enough to fill the cavity of the chorion com- 
pletely, this vitreous humour or reticulated body is no 
longer to be found. 

Up to ihe end of the third month, and in some in- 
stances to a later period, the embryo or fcetus is supplied, 
not only by what ihe vessels of the ovum absorb from the 
living surface of the womb, but also by the contents of the 
umbilical vesicle, which is a small sac as large as a pea, 
lying between the chorion and amnion, and connected by 
a stem, or channel, or duct, with the umbilicus of the 
child. This vesicle, or sac, is filled with a substance 
not unlike the yelk of eggs, which can pass along the 
duct above mentioned through the umbilicus and into 
the foetal intestine : an arrangement analogous to that of 
the chick in ovo, in which the membrane of the yelk is 
known to have a direct connection with the intestine of 
the chick, into the cavity of which the substance of the 
yelk passes freely, about the time it is hatched. 

If the student now reflects that the umbilical cord of 



104 PREGNANCY. 

the child, at term, is from twenty-five to thirty inches in 
length, and covered with a coat of amnion all the way 
to the navel, it seems to me that he will readily infer 
that the germ of the infant must have been originally 
situated betwixt the chorion and amnion ; and as it re- 
moves further and further from the chorion, it carries 
with it a reflection of the amnion, which to the latest 
period lines its umbilical cord : whereas it leaves its 
accessory organ of nutrition, to wit, the umbilical vesi- 
cle, betwixt the two membranes, and only carries along 
with it the duct or tube, which elongates proportionably 
with the umbilical cord. 

In regard to the existence of the allantois, I shall refer 
the reader to what M. Velpeau has said upon that head; 
because the subject being as yet imperfectly under- 
stood, I do not think this a fitting occasion to speak of it 
more at large. Under that head, however, I doubt not 
that all that can as yet be properly said, has been clearly 
exposed by that most ingenious and accurate writer. 

Within the amnion is contained a quantity of fluid 
denominated the water of the amnion, or in common 
language the waters ; it is never perfectly transparent, 
but has a milky appearance, not unlike that presented by 
a dilute mixture of buttermilk and water. Many flocculi 
are found in this liquid, which doubtless consist of coagu- 
lated albumen ; a small quantity of salts are also found 
in it. The source from whence it is derived is wholly 
unknown. The quantity varies in difl'erent individuals, 
amounting in some to three or four pints, and in others 
to not more than a few ounces. It serves to protect the 
foetus from the injurious succussions and shocks to which 
it would be liable but for the presence of the fluid, which 
serves as an elastic nidus or medium in which it grows. 

The womb increases pari passu with the ovum, and 
ceases to increase, and indeed begins to diminish in 
size, or to contract, whenever the water is drawn oflf 
or allowed to escape. I think that, whatever is the prin- 
ciple of vital mechanism by which the liquor amnii is 
introduced into that sac the amnion, no one can justly 
entertain the smallest doubt that it serves as a principal 
antagonist to that force which prompts the uterus al- 



PREGNANCY. 105 

ways to contract ; and hence this antagonizing use of the 
liquor amnii is to be assumed as one of its chief ends. 
It can in no manner serve for the nutrition of the 
child, for it exists at a period when no such function 
can be supposed of il ; and even in astomatous or acepha- 
lous children, and in such as are born with imperforate 
oesophagus, the liquor amnii presents its usual phenome- 
na, while the child itself is as amply nourished as if 
it were possessed of the most perfect conformation. 

The child turns freely in the cavity of the womb in 
the early stages of pregnancy. Its cord is then very 
short, and attached much nearer to the breech than to the 
head of the embryo, which hangs in the waters by the 
cord, as a pear by its stem ; whence the head, being the 
heaviest and largest end of the lever, falls lowest, so that 
when the child is to be born, it generally advances with 
the head first. Its proper situation throughout the entire 
pregnancy is with the head downwards, the breech 
being turned towards the fundus uteri. Some cases, 
hoM'ever, occur in which the pelvic extremity of the 
child advances first; and we are bound to believe, when 
such instances do occur, that the child has been in that 
attitude during all the latter months of the gestation. 
It is a very singular fact, and worthy of remark, that 
some women are met with who bring all their children 
into the world by breech presentations. A lady assured 
me that she had had five of her children born in this 
way, which were all she had borne. 

I see not how such a case can be accounted for, ex- 
cept under the supposition that they were all accident- 
ally so placed ; for nothing in her structure, or that of 
her infants could be discovered as likely to cause such a 
succession of untoward presentations. It is certainly 
possible that the child may be, without extrinsic aid, 
occasionally turned in the womb at a late period of preg- 
nancy, but such an occurrence has very rarely been met 
with. Up to the fifth month, such mutations could take 
place without difficulty ; but when the child has attained 
a greater size, it is not at all likely to happen. The 
observation of an immense number of obstetric cases in 
France, shows that about one child in twenty-eight is 



106 PREGXANCr. 

bom by the breech presentation, while the head pre- 
sentations were twenty thousand six hundred and ninety- 
eight, out of twenty-two thousand two hundred and forty- 
three cases. 

As the ovum expands, it carries the uterus along with 
it. making use of the cavity of the fundus and body of 
the or^an at first, and Only distending the upper part of 
the cervix in the first months of pregnancy, so that if an 
examination should be made of a woman three months 
pregnant, the tubulated cervix uteri would be found to 
have undergone very little perceptible shortening. 

The cervix certainly becomes fuller and larger at a 
very early period of pregnancy, and presents, in this 
respect, a sensible difference from its unimpregnated 
state. At the close of pregnancy the cervix uteri seems 
to have wholly disappeared, and the womb, instead of 
exhibiting a tubulated or cylindrical neck, is become an 
oval, the OS lincse beinff at the lowest end. Xo decided 
change in the length of ihe cylindrical part is discovered 
by the touch until after the fifth month, or according to 
certain authorities the seventh month. From that period 
it grows daily shorter, until the last days of gestation, when 
it is not to be discovered at all. A pregnant woman, there- 
fore, in whom it has wholly disappeared, is said to be 
ready to commence the process of labour. The attack 
of labour paius may begin very soon after the disappear- 
ance of the cervix, or it may be deferred for several days, 
from causes which are not understood. The Jig^ures 
exhibit the form of the gravid uterus ; ichich may he 
compared with that of the unimpregnated orgayi. 

In all instances that have fallen under my notice, the 
thickness of the walls of the womb, when at term, has 
been rather less than in the non gravid organ. The tis- 
sue is much looser and easier to cut. and yields to any 
distending force far more readdy in the g-ravid, than in 
the non gravid state. It is incomparably more vascular, 
so that in the last weeks of gestation it may be com- 
pared to a purse, or network of blood vessels, with an 
abundance of loose cellular tissue and muscular fibres 
interspersed. The uterine arteries and veins which 
reach the womb near its lower extremity inosculate 




106 




106 



1 



PREGNANCY. 107 

freely with the ovarian or spermatic vessels, that enter 
its texture betwixt the folds of the broad ligaments, and 
supply the ovaria, the Fallopian tubes and upper por- 
tions of the womb. 

With regard to the muscular structure of the womb, I 
shall remark that no person who has witnessed the exer- 
cise of it in labour, can doubt of its immense power, 
and particularly should he have felt it while the hand 
has been compressed by it in turning a child in utero. 
Some years since, a gentleman of this city, found him- 
self obliged to introduce his hand completely into the 
womb, in order to extract a retained placenta. While the 
hand was employed in separating the afterbirth from the 
uterus, the os uteri closed upon his wrist with such 
force as to give him very severe pain, and he found it 
impossible to withdraw the hand, which was completely 
fastened by the contraction. After various unsuccessful 
attempts to extricate himself from such an unheard of 
difficulty, he sent for a bleeder, and after causing a large 
quantity of blood to be drawn from the lady, the spasm 
of the cervix ceased, upon v/hich he was liberated from an 
imprisonment of two hours. His wrist was marked as 
if a cord had been strongly bound round it, the traces 
of which impression were visible even the next day. 
The operation of turning the child, in a powerful womb, 
from which the waters have been entirely drained, 
not unfrequently produces a degree of numbness, from 
pressure, so great as to make it necessary to withdraw 
the one and introduce the other hand ; the sensibility 
and motion of the first one being wholly suspended. 
The resistance to be overcome in the expulsion of a 
grown foetus, requires a muscular force which cannot be 
exactly estimated, but which must be very great. 

Different writers describe the arrangement of the mus- 
cular fibres of the uterus in different manners. The 
very discrepancies of these authors ought to convince us 
that the arrangement is not well understood ; and indeed 
it is of no great consequence, in a practical view, that 
they sliould be demonstrated. It is enough to know that 
they are so arranged as to tend, by their combined con- 
tractions, to reduce the uterus back from the gravid size 



f 



108 PREGNANCY. 

to that of the unhnpregnated organ. When their con- 
traction is co-ordinate, the fundus tends to approach the 
OS tincae, and the sides tend to approach each other. 
Whatever is contained within the cavity of the organ is, 
under these circumstances, expelled therefrom. 

Labour does not, however, always proceed with regu- 
larity. The muscular power of the womb is occasion- 
ally found to be morbidly exercised. Those fibres 
which tend to bring the fundus near the os tinc^, some- 
times fail to act, or act imperfectly, while those that 
tend to approximate the sides of the womb, act with 
such force as to compress the body of the fcetus, and 
instead of expelling it, rather confine and retain it within 
the cavity. We frequently observe women to sufi'er under 
the most violent uterine pains, which nevertheless do not 
move the child downwards in the least degree : such 
pains should be suppressed, if possible, in order to ad- 
mit of the co-ordinate and regular operation of all the 
fibres being restored, after a temporary cessation or 
repose. It is such an action as this which constitutes 
the hour-glass contraction of the womb, whereby the 
placenta is occasionally retained, instead of being natu- 
rally extruded ; a case of much difficulty, embarrass- 
ment and even danger. 

As the ovum increases in size, the womb augments 
proportionably. It becomes too large to occupy the 
pelvic excavation, and then rises into the abdomen. 
The pelvic cavity is four inches by five in diameter; the 
womb, at term, is from seven to eight inches in trans- 
verse, by twelve inches in longitudinal diameter. It 
rises out of the pelvis at the fourth month, or at four 
and a half months, which is the period of Quickening. 
It has been contended that "quickening" is a sensation 
produced by the sudden escape of the globe of the womb 
from out of the pelvis ; and the intrusive organ is supposed 
to excite this curious sensation by its sudden entrance 
into the lower part of the abdomen. It will not be 
doubted that such a case might occur, and produce by 
its very suddenness the agitation or fainting that is some- 
times observed to accompany the first " quickening ;'* 
but it is far more common and natural for the fundus 



PREGNANCY. 109 

Uteri to come slowly upwards and take its place in the 
hypogastrium, without causing any agitation or disorder 
whatever. In such a case, the quickening will be per- 
ceived as soon as the child acquires muscular power 
sufficient to make itself felt by the mother, whenever it 
forcibly extends any one of its members against the inner 
surface of the womb. This takes place from the end of 
the sixteenth to the end of the eighteenth week, some 
being earlier and some later. 



Upon examining a pregnant woman per vaginam, at 
the second or third month, she M'ill be found to have 
the OS uteri somewhat depressed, or prolapsed towards 
the orifice of the vagina, and this to such a degree as to 
cause her to complain of symptoms of a falling of tlie 
w^omb. After the quickening has taken place, these 
symptoms disappear, and, upon examination, now re- 
peated, the OS uteri is discovered to be very high up, 
and generally directed towards the promontory of the 
sacrum, or at least towards the upper part of the curve 
of that bone. As the longitudinal axis of the womb 
ascends in the direction of the axis of the superior 
strait, the reader perceives that the anterior face of the 
lower portion of the womb must rest on the pubis, while 
the body of the uterus lies upon the peritoneal covering 
of the abdominal muscles : the bowels are behind the 
organ and above it. 



Both the projection of the sacrum and the intrusion of 
the spinal column, tend to give to the womb an oblique 
direction, and hence we generally find it to be inclined 
towards one side of the abdomen. So far as my obser- 
vation enables me to speak, it is oblique to the left more 
frequently than to the right side. Great degrees of 
obliquity are scarcely met with in first pregnancies, in 
consequence of the vigorous contractility of the abdomi- 
nal muscles, which constrain the gravid womb to remain 

K 



110 PREGNANCY. 

in the mesian line ; whereas, in women who have borne 
many children, those muscles acquire such a laxity and 
want of tone, as to allow the womb to librate from side 
to side, or in front, according to the attitude of the pa- 
tient for the time being. Of the effects of obliquity we 
shall speak when we shall come to treat of labour. 



Women, in whom the abdominal muscles have not lost 
their tone by repeated extensions in pregnancy, will be 
found to compress the uterus strongly, in a direction 
towards the back; whereas those whose abdominal 
muscles have become weakened by repeated gestations, 
carry the child very low, to use a common term, allow- 
ing the enlarged womb to recline upon the muscles in 
front of it. In the former case, the pressure of the organ 
against the spine must, to a greater or less degree, in- 
terfere with the current of blood in the great vessels of 
the abdomen ; hence the aorta and iliac arteries, and 
some of their branches, will pass on their contents with 
less freedom than is common, whereby the upper parts 
of the body are supplied with more than their due pro- 
portion of the blood. Headach, vertigo, flushings of the 
face,' and tendency to paralysis and convulsions, may 
very properly be attributed to the excessive momentum 
of the blood, distributed to the superior parts, and deter- 
mined towards them by this cause. Sighing, praecordial 
distress, dyspnosa and coughs are also found to depend 
upon the same principle, and are to be treated with a 
view to lessen this vicious distribution and accumulation 
of the vital fluids. Venesection, looseness of the bowels, 
light diet, and whatever tends to produce moderate re- 
laxation of the muscular forces, are in general employed 
with signal success in these circumstances. 

I have frequently met with coughs in the latter weeks 
of pregnancy, which proved rebellious against all treat- 
ment, until the delivery of the patient, after which they 
yielded to the common means of cure : the pressure 
of the womb on the abdominal vessels being removed, 



PREGNANCY. Ill 

the pulmonary irritations previously sustained and en- 
forced thereby, proved no longer indomitable. 

The same pressure of the enlarged womb, above spoken 
of, interrupts the return of the blood from the extremi- 
ties, and the transit of the contents of the lymphatic 
absorbents. Hence, when that pressure has reached its 
maximum, the feet and legs become oidematous or ana- 
sarcous ; the veins of the feet and legs acquire an enor- 
mous size, and become permanently varicose, and in cer- 
tain instances burst, so as to cause effusions of blood to 
take place. In like manner as has been stated of the 
superior or arterial engorgements, this inferior or venous 
engorgement ceases upon the abstraction of its cause. 
Limbs when swelled even enormously, are observed to 
recover their natural size in three or four days after the 
accouchement. The same general plan of treatment is 
applicable to both the cases ; but it is particularly in- 
cumbent upon the medical attendant to employ, in the 
latter case, rollers for the limbs, that may enable their 
vessels to overcome the distending causes. Where the 
oedema is very great and painful, punctures with a lancet, 
extending into the tela cellulosa, allow the serum to 
escape, and thereby are the means of procuring very 
great relief, without the least danger, or any inconve- 
nience worthy of attention. 

In some cases the oedema of the limb is so great, that 
it extends, at length, even to the perineum, the labia and 
the lower part of the abdomen. I have met with in- 
stances in which each labium was swollen to four or five 
times its natural size, from this serous infiltration. In 
some of these cases the tumour has been hard and very 
resisting. I found it necessary on that account to punc- 
ture them, in order to admit of the reduction of the size, 
before the child could pass forth of them ; but, for the 
most part, such punctures are not required, since the 
pressure of the advancing presentation suffices to compel 
the serum to flow out of the labia and perineum into 
collateral cells of the tela cellulosa. 



112 PREGNANCY. 

The placenta, the cord, and the membranes, constitute 
what is called the afterbirth, or secundines. It is com- 
monl)'' supposed and taught, in this country, upon the 
authority of Mr Hunter, that the placenta is an organ 
composed of two distinct parts, one derived from the 
mother and the other belonging to the foetus : that the 
maternal part is formed out of the decidua, and the foetal 
part out of the vessels of the umbilicus : that the blood- 
vessels of the mother pass freely into the maternal part, 
and pour their sanguine fluid into certain cells contained 
in it, while the vessels of the fcetal umbilicus either 
pump up this fluid and take it to the embryo, or at 
least derive from this blood some oxygen, or deposit 
there some carbon, so as to effect here the office which, 
after birth, is performed by the lungs. Mr Hunter's 
authority in physiology and anatomy is so justly vene- 
rated, that it may seem arrogant in any one to venture to 
differ from him ; but nevertheless I cannot agree with 
this view of the foetal state. Having adopted other views, 
I shall proceed, as follows, to lay them before the reader, 
leaving him to adopt or reject them upon his own judg- 
ment. 

The child is connected with the mother by means of 
the Placenta, which should be regarded as the capillary 
portion of that system of blood-vessels which is project- 
ed from the body of the embryo, in order to establish its 
union with the parent. The placenta is a production of 
the outer surface of the chorion, or, I might say, it is a 
thickened portion of the chorion, of which it is part and 
parcel, and from which it can never be separated, except 
by violence. At full term, this substance, the placenta, 
is from seventeen to twenty inches in circumference, 
and above half an inch in thickness, at its thickest part. 
It is attached to the uterine surface by a moderate ad- 
hesion, except in a few rare instances, in which the 
union is more intimate ; but on all such occasions, the 
attachment ought to be considered as morbid, or unna- 
tural. 

I have seen a womb, containing a foetus at full term, 
taken from the body of the mother not long after her 
decease. The uterus was laid open by an incision ex- 



PREGNANCY. 113 

tending from the fundus to near the os uteri ; this cut 
exposed the chorion : the cut edge of the womb being now 
turned back from the chorion, parted from it without the 
least difficulty. Upon continuing to peel the uterus off 
from the chorion, the thin edge of the placenta came into 
sight ; and as soon as it was seen, the greatest pains 
were taken to separate the womb from the afterbirth 
slowly and gently ; and upon the most careful observa- 
tion, with the eyes directed to the line where the sepa- 
ration was taking place, not a single blood-vessel was 
discovered passing from the placenta to the womb, or 
from the womb to the placenta. The slightest force 
only was required to effect the detachment, and the ad- 
hesion was not near so firm as is often observed betwixt 
the skin and a good adhesive plaster. When the detach- 
ment was completed, nothing was left adherent to the 
womb, and no projecting ends of broken blood-vessels 
were to be found, nor any effusion of blood or seriim. 
The patient had died only a few hours before. The 
uterine face of the placenta was left smooth, and so was 
that of the womb. 

I have had more than one opportunity of witnessing 
this detachment, under the most careful attention and 
anxious desire to discern with the eye, any traces of 
vascular connection of the two organs : I have not been 
able to discover any such thing. The evidence of my 
own senses, therefore, compels me to reject the opinion 
of a vascular anastomosis, or a continuous vascular 
union in the utero-placental structure. I am compelled 
to think that the afterbirth is merely adherent to the 
womb, and derives from that organ the material for the 
nutrition of the child, and the decarbonization of its 
blood, as well as the needful supply of oxygen. 

I can never, I think, be persuaded that, if so strong a 
union as is contended for by Mr Hunter did exist, the 
uterus could, by its own contractions, peel the secun- 
dines off from its surface ; nor that I could, as I have 
many times done, detach it with my fingers, introduced 
into the uterus in cases of a morbid retention of the sub- 
stance in question. I have already said that the skin of 
a ripe orange does not more easily part from the fruit, 



114 PREGNANCY. 

by peeling, than the placenta parts from the surface to 
which it is naturally attached. I leave it to the intelli- 
gent reader to decide, supposing my statement to be 
correct, whether such tissues as arteries, and veins, and 
capillary vessels, which it is pretended pass freely from 
one to the other of these organs, could be broken off 
with such slight force ; and I might further, in support 
of this view of the subject, ask wherefore such a strong 
vascular union in the human female, when it is admitted 
that none exists in the other mammalia ? The mechani- 
cal or structural principle by which the embryo is nou- 
rished must be the same in all orders of the mammalia, 
and few persons pretend that there is vascular union of 
the placentulae and cotyledons in the pecora, in the 
zone-like placenta of the genus felis, in the placentula 
of the rat, &lc. 

Let the reader, who wishes to satisfy his mind upon 
this subject, take an opportunity to examine the gravid 
uterus of the cow, the sheep, the cat, the rat, the mare, 
&;c., and he will immediately perceive, that although 
these animals bring their young to perfection as well as 
the human female, they certainly do not furnish the 
least evidence of a vascular union, or of any thing more 
than a moderately firm adhesion of the placental part of 
the ovum to the gestative organ; and nature is too sim- 
ple and economical in the use of her means or laws, to 
deviate in one of the mammalia, from a principle which 
is of universal application in the remaining genera. 

From the foregoing remarks, the student will perceive 
that I desire to inculcate the opinion that there is no ute- 
rine part of the placenta ; that it is altogether foetal ; and 
that, whether it be separated in the second month or at 
the end of the ninth, or at any intermediate stage of preg- 
nancy, the whole ovum, the entire product of conception 
comes off, and leaves the womb absolutely empty, 
bringing with it nothing that belongs to the womb. 

I am well aware that this opinion is not in accordance 
with that of Mr Hunter, nor that of many of my medical 
friends here, but I cannot, however strongly I might 
desire to agree, upon these facts, with those whose views 
are entitled to my highest respect — I cannot forego the 



PREGNANCY. 115 

convictions that I have formed from observations made 
with my own eyes, and which are also supported and 
enforced by such a writer as M. Velpeau, whose accu- 
racy and candour give him claims to credence, on this 
point, not less in degree than is due to any writer of 
ancient or modern times. 

Should I be asked wherefore the uterus bleeds so vio- 
lently when the placenta is separated from it, and whether 
sucli large effusions of blood could be expected to take 
place were there no ruptured vessels in the case of such 
detachment, I have this answer, that the uterus is, in the 
gravid state, a highly vascular and sanguine organ; that 
it has a natural proneness to hemorrhagic irritations, 
and that it bleeds as easily as, but scarcely more readily 
than the Schneiderian membrane, whenever it is the seat 
of an hemorrhagic irritation ; and that as we do not attri- 
bute to the common epistaxis, even when most profuse, 
a traumatic character, so Ave need not feel compelled to 
suppose a traumatic state in every instance of uterine 
hemorrhage in pregnancy. I might furtlier answer that 
uterine hemorrhage often ceases upon the application 
of cold, the exhibition of sugar of lead, of alum, and 
other styptics, or upon venesection ; and the same reme- 
dial results are obtained in epistaxis, hsemoptoe, or hae- 
matemesis. I am, therefore, not moved from my senti- 
ment by the question supposed ; but rather confirmed by 
the analogies that I can discover in other instances of 
effusion of blood. It is also very certain that the womb 
does not always bleed when the placenta is detached. I 
frequently have received an afterbirth which was not in 
the least soiled with blood. I once, in turning a child 
that presented by the shoulder, found the afterbirth 
wholly detached ; I even took it in my hand while ex- 
ploring the womb for the child's feet, and nevertheless, 
there was no hemorrhage. Upon one occasion I was 
invited by Dr Shaw of this city, to visit with him a patient 
who had a shoulder presentation. While his hand was 
in the uterus, and before he had found the feet, he said 
to me, '* The placenta is entirely detached, and loose ; 
I have it now in my hand." In that instance, also, there 
was no hemorrhage, and the child was delivered alive. 



116 PREGNANCY. 

Now I am unable to comprehend, in the first place, how 
the placenta could be wholly detached in an uncon- 
tracted womb, if it were united by strong- blood-vessels ; 
and secondly, how it could fail to bleed profusely in 
either of the above mentioned cases, had there been any 
rupture of blood-vessels. Surely, if a multitude of ves- 
sels as large as crow-quills could have been broken off, 
the child being still in utero, they could not possibly 
have failed to furnish a large and dangerous effusion of 
blood. I shall, therefore, with great confidence conti- 
nue to entertain the same sentiments I have long held 
upon the mode of connection of the womb and the 
ovum. 

The placenta is scarcely more than a congeries of 
arteries, and veins, and capillaries, united in bunches, 
by means of a cellular tela. These bunches constitute 
certain lobules, which are not very visible until the pla- 
centa has been bent towards its fostal surface, so far as 
to break it, when they become apparent. Each lobe or 
lobule is united to the others by a common cellular 
union. 

The use of the placenta is twofold : as, first, to afford 
a point of direct contact of the vascular circulation of the 
child with the living surface of the mother — and it 
should be here noted, that everywhere else, except at 
the placenta, the child has a chorion and amnion inter- 
posed betwixt it and the mother, so that if the child does 
absorb or imbibe the materials for its nutrition from its 
parent, this is the only point at which that acquisition 
can be made ; and secondly, that the placenta serves as a 
branchia, or gills, a substitute for its yet undeveloped 
lungs, and that it excretes here its ^carbon, and receives 
its oxygen, without some apparatus for which, it would 
speedily die of asphyxia. In fact, we see children perish 
very speedily with asphyxia, whenever, in consequence 
of pressure on the cord, or total detachment of the 
secundines, they lose their only means of getting a sup- 
ply of arterialized blood. 

I am acquainted with no facts that are indisputably in 
evidence of the existence of any considerable absorbent 
vessels in the placenta or the cord ; nevertheless, if the 



PREGNANCY. 117 

child be in contact with its mother at no other point than 
that by which its placenta touches her, it must follow 
that the child does there absorb, imbibe, or in some 
manner acquire the means of its increment. There are 
authors who are disposed to take up again the exploded 
notion of an absorbing power in the veins : but it is far 
easier for me to believe that there may exist many short 
absorbents leading from the surfaces on which they open 
directly into the nearest veins, and on that account not 
yet distinguished from the veins by the art of the anato- 
mist; than it is to admit that a vein, which is nothing 
more than a continuous artery or capillary vessel, should 
be endowed with the power of absorbing. It is true 
that many instances are recorded of injections having 
been thrown from the vessels of the mother into the 
vessels of the fcetus, and vice versa, and this is said to 
take place not only in the human female, but also in the 
case of other mammalia. Biancini informs us, for ex- 
ample, that by injecting the vessels of a woman, the 
placenta being still undetached, he found the matter of 
injection had penetrated the tortuous arteries of the 
womb — passed into the tissue of the placenta, and spread 
itself over the membranes. He also succeeded in in- 
jecting the veins of the foetus in a cat, by filling the 
uterine arteries. In another experiment he threw an 
injection into the umbilical arteries of a calf, and found 
that it passed directly into the placenta, by nine short 
cylindrical branches, which he calls placento-uterine 
veins. These statements might be deemed sufficient to 
insure our assent, were it not that multitudes of other 
attempts have been in vain made to procure similar 
results, and that the supposed success of them can be 
accounted for on the hypothesis that rupture readily 
takes place in dead tissues, by which means fluids enter 
into routes from which they are whoUv excluded during 
life. 

I have, many times, counted the pulsations of the fcetal 
heart, in utero, by means of auscultation, and have found 
that pulse varying from one hundred and thirty to one 
hundred and forty beats per minute, while the mother's 
heart was pulsating at the ordinary rate. I take this 



118 PREGNANCY. 

fact as at least a strong argument in favour of the opinion 
of those who regard the fostus as an independent being, 
particularly if considered in conjunction with this other 
fact, viz. that the blood of the foetus is always dark, 
like venous blood. 

The placenta may be situated on any part of the ute- 
rine surface. It may be found upon the fundus, on one 
of the Fallopian orifices, on the bas-fond, in front, on 
either side, or upon the inner os uteri. In the latter 
situation great danger arises to the woman, inasmuch as 
the placenta must be detached wholly, or in part, before 
the OS uteri can be opened sufficiently for the exit of the 
child : it is the much dreaded placenta praevia. 

The blood reaches the placenta by the two arteries of 
the umbilical cord, and escapes by a single vein. Its 
route is as follows. The contraction of the left ventricle 
of the foetal heart propels the wave of blood into the 
aorta, through which it flows, along the internal iliacs* 
the hypogastrics and the umbilicals, into the placenta ; 
it enters there into the radicles of the umbilical vein, by 
which it is transferred along the cord to the navel. 
Upon re-entering the abdomen through the umbilical 
ring, it passes along the edge of the falciform ligament 
of the liver, and enters the vena portae ; across which a 
part of the current flows, in order to enter in at the duc- 
tus venosus, which empties it into one of the hepatic 
veins, or into the lower cava; the remainder of the cur- 
rent flows along with the portal blood into the hepatic 
vessels, and is taken up by the hepatic veins, to be cast 
into the common system of the cava, so that the whole 
of the placental blood which had been separated in the 
portae, is reunited in the cava. In the cava it moves up 
to the right auricle, and passes directly through the sep- 
tum auriculorum, by the foramen ovale, into the left 
auricle, and thence into the left ventricle, and so into the 
aorta again. 

While the blood that comes from the placenta takes 
the route above mentioned, in company with the blood 
from the inferior extremities of the child, that part of the 
foetal blood which has circulated in the head, the arms 
and upper parts of the body, is collected in the upper 



PREGNANCY. 119 

cava, which also opens into the right auricle ; but this 
current is thrown across the auricle to the right ventricle, 
and does not mix with that from the lower cava, and 
which, as I just now said, passes directly from the cava 
to the left auricle. When the blood of the upper cava 
has thus reached the right ventricle, it is propelled into 
the pulmonary artery, and advances towards the lungs, 
into which a portion of it enters and returns by the pul- 
monary veins to the left auricle, and thence to the left 
ventricle ; but by far the larger portion does not enter 
the lungs at all, but is driven through the ductus arterio- 
sus, which leads from the pulmonary artery into the 
aorta, to a point below where the carotid and subclavians 
are given off. 

Under this arrangement it is evident that all the blood 
that has circulated in the head and upper extremities, 
must descend the aorta before it can return to those parts ; 
whereas that which has just come from the body and 
the lower extremities and the placenta, escapes from 
the left ventricle in a direction which favours its ascent 
to the carotids and subclavians. Hence it is, perhaps, 
that the head and superior members are more rapidly 
evolved than the other parts of the child, being in this 
way supplied with the greatest abundance of revivified 
or oxygenated blood. It is not to be supposed that 
every drop of blood coming from below is in this way 
carried to the head and arms, or that all which has been 
above must descend to the lower parts and to the pla- 
centa ; there must be, to a considerable extent, a com- 
mixtion of the two kinds : all that is contended for is, 
that the major part of the fluid moves as above indicated. 

From the foregoing it will be seen that the peculiarity 
of the foetal circulation consists in its possessing, first, a 
ductus venosus in the liver, by means whereof a part of 
the blood of the placenta proceeds directly onwards to 
the heart, and another part goes by the circuitous route 
of the hepatic portal vessels, the hepatic veins and the 
cava; and second, a foramen ovale, admitting of the 
immediate transit of the blood of the right auricle into 
the cavity of the left auricle ; and third, a ductus arterio- 
sus, by which the blood of the right ventricle is thrown 



120 PREGNANCY. 

into the aorta, below its three first great trunks ; and 
fourth, a set of umbilical vessels, through which the 
whole sanguine fluid of the child may be, by successive 
portions, brought into close contact with the vital sur- 
faces of its mother. The foetus, in this sense, might 
almost be said to touch its mother only by its blood. 

The child, in the uterus, grows very rapidly in the 
last three months of its gestation, and is supposed to be 
not perfectly developed until the completion of the ninth 
month ; yet many cases are met with in which the child 
is born several weeks before its time, and thrives as well 
as others that remain in utero to the full period. Many 
persons are brought to bed of the first child rather sooner 
than the regular computation would lead them to expect 
that event, and not a few are to be observed who inva- 
riably fall into labour at the end of the eighth month, 
giving birth to very healthy offspring. 

The common duration of pregnancy is two hundred 
and eighty days, or forty weeks, but there is a great 
latitude in the duration of the process, both in women 
and the inferior animals. 

Dr Merriman, of London, has published, in vol. xiii. 
part ii. of the London Medico-Chirurgical Transactions, 
a paper on the Period of Parturition, which contains an 
interesting table of the births of one hundred and four- 
teen mature children, calculated from, but not including 
the day on which the catamenia were last distinguish- 
able. 

By this table it appears that three were born in the 
thirty-seventh week, thirteen in the thirty-eighth week, 
fourteen in the thirty-ninth week, thirty-three in the 
fortieth week, twenty-two in the forty-first week, fifteen 
in the forty-second week, ten in the forty-third week, 
and four in the forty-fourth week, of which latter, one 
was born at three hundred and three days, one at three 
hundred and five days, and two at three hundred and six 
days. 

Dr Merriman states that he has calculated a great 
many more cases in the same manner, but has restricted 
his table to the above one hundred and fourteen cases 
because he was able completely to verify them ; the 



PREGNANCY. 121 

Others gave results so nearly similar, that he has no 
doubt of the general correctness of the principle he de- 
sired to enforce, which was, that conception takes place, 
in general, soon after the cessation of the catamenial 
flow, and not just antecedently to its expected return* 
The table is highly interesting, in the relations for which 
I would use it, showing, as it does fully, that there is a 
considerable latitude in the duration of gestation. 

M. Tessier, in France, caused a set of observa- 
tions to be made on the duration of pregnancy, in one 
hundred and sixty cows, which commonly go nine 
months with young. Three of these cows brought 
forth on the two hundred and seventieth day ; fifty of 
them from the two hundred and seventieth to the two 
hundred and eightieth day ; sixty-eight from the two 
hundred and eightieth to the two hundred and ninetieth ; 
twenty went to the three hundredth ; and five did not calve 
until the three hundred and eighth day, which is thirty- 
eight days beyond term — whereas fourteen of them calved 
from the two hundred and forty-first to the two hundred 
and sixty-sixth ; which is a latitude in the cow of sixty- 
seven days. The mare goes eleven months with young. 
Of one hundred and two mares, three foaled on the three 
hundred and eleventh day ; five from the three hundred 
and tenth to the three hundred and thirtieth ; forty-seven 
from the three hundred and fortieth to the three hundred 
and fiftieth ; twenty-five from the three hundred and 
fiftieth to the three hundred and sixtieth; twenty-one 
from the three hundred and sixtieth to the three hun- 
dred and seventieth ; and one on the three hundred and 
ninety-fourth day : a latitude of eighty-three days. For 
the above account I am indebted to Velpeau, vol. ix. 
p. 246. The child quickens about the twentieth week, 
or a little earlier or a little later ; so that if a female com- 
pute forty weeks from the last menstruation, or twenty 
weeks from the first feeling of the motions of the child, 
she may make a tolerably sure calculation of the time of 
her labour : nevertheless, they make very great mistakes ; 
either because there is a great latitude of the duration ; or 
because the pregnancy may take place just before the 
catamenia, instead of just after it, which will give a dif- 

L 



122 PREGNANCY. 

ference of from twenty to twenty-five days ; or lastly, 
because some women quicken much earlier than others. 

The child may live if born at seven months complete, 
or even at six months complete ; but in the latter case it 
is considered as non viable, however strongly a few 
striking" exceptions might tempt one to admit it as viable. 

Previously to the seventh month, the septum auriculo- 
rum is still so pervious at the foramen ovale, that as 
soon as the child attempts to breathe, it becomes livid, in 
consequence of a major part of its blood passing at once 
into the left auricle : the pulmonary artery and its branches 
being not sufficiently developed to receive the whole 
torrent ; and the foramen ovale not being yet sufficiently 
contracted to keep the current from traversing the sep- 
tum. As the child approaches the term, the foramen 
ovale becomes more and more constricted ; and of course, 
the pulmonary arterial branches more and more deve- 
loped; and the child, of course, more and more fitted for 
respiratory life. After birth, and the establishment of 
regular respiration, the foramen ovale gradually closes ; 
the ductus arteriosus ceases, by degrees, to conduct off 
the blood of the pulmonary artery ; and as the umbilical 
vein is no longer employed, its tissue becomes a mere 
ligament, while the umbilical branches of the hypogas- 
trics also disappear ; and the last vestiges of the foetal 
peculiarities are at an end. 



The signs by which a woman knows herself to be 
pregnant are, the cessation of her regular menses, and the 
subsequent enlargement of the abdomen and the move- 
ments of the foetus. 

A married woman, who has been well regulated, sus- 
pects that she has conceived, if she fails to menstruate at 
the proper term ; but this cannot be ever considered as 
conclusive evidence of conception, since so many and 
such various causes are found to obstruct and avert the 
regular course of the menstrual function. A second 
failure, especially if it be not accompanied with any 
signs of depraved health, renders the suspicion still more 



PREGNANCY. 123 

valid ; while after a third and a fourth omission, the 
change of form, and at last the perceptible motion of the 
embryo put all doubt to flight. I may say, however, 
with great confidence, that tlie audible or visible move- 
ments of the fcEtus afford the only true and infallible 
signs of its existence. 

There are many accidental or correlative signs which 
enforce the probability of the existence of pregnancy : 
among wiiich I may mention, nausea and vomiting; a 
gradual increase or development of the mamma; a change 
of the areola of the breast, which acquires a dark brown 
hue, and is much relied upon, especially in first preg- 
nancies. The nausea is mostly found to occur in the 
morning, and is attended in some individuals with a 
distressing heartburn, and a salivation, or spitting of 
saliva. Some people are affected with gravel, or dysury, 
from the extension of irritation to the neck of the blad- 
der, or the pressure of the enlarging womb upon the 
posterior surface of that organ. An irritable state of the 
temper indicates it in some women, which is attributable 
to the general malaise that must attend the gastric em- 
barrassments which the early stages of pregnancy are 
so commonly found to produce. Tooth ache, ear ache, 
sties on the eyelids, morph on the skin, a dark circle 
around the eyes, and strange unaccountable longings or 
appetites, are also signs of pregnancy, rather to be noted 
after pregnancy is fully ascertained, than to be depended 
upon as sure evidences of its existence. 

By means of the Touch, pregnancy may be pretty 
surely ascertained, before quickening has taken place. 
I might here say, that, by the touch we can readily 
learn that the womb is enlarged, altered in form, and 
contains something ; but I do not see how any physi- 
cian can absolutely aver what that something is, unless 
he can perceive a spontaneous motion in it; so that even 
the bcdlottement, or tilting the embryo upon the point of 
the finger, does not furnish, to my mind, any sure evi- 
dence that the tilted body is an embryo. I adhere, 
therefore, to the opinion 1 have already expressed, that 
we have no certain signs except those derived from the 
visible or audible motions of the child. 



124 PREGNANCY. 

Auscultation, either by means of the stethoscope or 
by the direct application of the ear to the abdomen of 
the woman, enables us to perceive two very distinct 
sounds, one of which is the beating of the heart, and the 
other is that which has been called the placental souffle, 
or bellows-like sound ; the latter being occasionally 
attended with a sound like the cooing of a dove. When- 
ever we can distinctly hear the beating of the fcetal 
heart, so as even to count the number of its pulsations, 
all doubt must be at an end. The placental sound, or 
the souffle, is a very distinct sound, and indicates not 
only the presence of a fcstus, but it also shows that it 
continues to live, the rushing or blowing sound always 
ceasing as soon as the foetus expires : it is, in some 
way, not yet sufficiently understood, connected with the 
movement of the blood in the placenta, and ceases, of 
course, with the cessation of that movement, which is 
itself dependent on the systole of the fcetal heart. 

It is of less consequence to be able to ascertain the 
existence of pregnancy in the married than in the un- 
married woman. By the lapse of twenty weeks it be- 
comes surely known ; and the married woman, who has 
no motive to keep it as a profound and important secret, 
readily imparts a knowledge of her situation, or her sus- 
picions relative thereto, to the physician, or her friends. 
Not so with the unmarried female, whose reputation is 
set at stake upon the concealment of her misfortune, or 
her crime contra bonos mores. I have been frequently 
very sorely embarrassed by uncertainty as to the condi- 
tion of a patient whose ruddy cheeks and embonpoint^ 
seemed quite incompatible with a suppression of the 
catamenia, and whose complaints of aches and pains 
might possibly be only assumed as a means of deceiving 
the medical adviser. Physicians are frequently applied 
to by the unfortunate or guilty for relief from " obstruc- 
tions,'^'' when the applicant knows full well her design 
is merely to purchase some powerful deobstruent or 
emmenagogue, which may serve to procure an abortion, 
that she knows no honest or respectable medical prac- 
titioner could be induced to procure, for any pecuniary 
reward whatever. I hold it to be a duty, in all cases ^ 



PREGNANCY. 125 

or ranks, to compare the complaints of amenorrhoea with 
the appearance of the patient, and if some evident 
malady does not accompany the supposed suppression, 
to withhold all medical aid, until time or necessity 
disclose the indications that are to be fulfilled. It 
is too much to expect that a female, who has it at 
heart to conceal her pregnancy, will confess it to a 
medical man. I was requested some time since by a 
lady to visit a favourite servant, whose situation excited 
her apprehension, as she had failed to menstruate for 
the antecedent seven months, and was already consi- 
derably swollen with something like dropsy. Being 
directed to the young person's apartment, 1 found her in 
bed, covered up to the throat with bed clothes, but the 
face that peeped out from above them actually shone 
with ruddy health, or agitation, or both. The pulse was 
natural, the tongue clean, the respiration natural, and 
the entire physiognomical expression as healthful as 
possible. She informed me that she had had a stoppage 
of the courses for the last seven months, and felt very 
bad, and was now alarmed at a swelling of the stomach, 
which had increased greatly of late. Suspecting that she 
had an important secret, I asked some questions about 
pains in the stomach, and upon permission obtained, 
placed my hand on the abdomen, being almost certain 
that I should feel the motions of a fcetus ; but, however 
long I held my hand on the abdomen, no movement of 
a child could be felt ; so that, although I was certain 
that she was pregnant, I was as yet unprepared to tell 
her so. I at length got permission to apply the ear 
against the side of the abdomen, and distinctly heard the 
placental souffle, and afterwards the stroke of the foetal 
heart. Upon this assurance I told her she was preg- 
nant. " If 1 am," she replied, '* I wi- h God may strike 
me dead," and continued, with much temper and even 
passion, to declare that I maligned her and slandered 
her. I was obliged to leave her without the least assent, 
on her part, to my diagnosis, although she knew per- 
fectly well that I spoke only a truth with which she had 
been long acquainted. She went out of town, and was 
confined in the country with a fine boy. Many exam- 



126 PREGNANCr. 

pies of similar perverseness, in denying pregnancy, the 
signs of which were perfectly plain to me, and ought to 
have been obvious to the most careless observer, have 
fallen under my notice ; so that I deem it a solemn duty, 
previously to the exhibition of emmenagogue medicines, 
to ascertain that some signs of disordered health are 
present, in order that I may not commit the unpardon- 
able fault of promoting an abortion, instead of remov- 
ing a morbid obstruction of the catamenia. 

There are many persons so ignorant of their own 
moral duties, or so uninstructed as to the character and 
duties of medical men, as to come to them with a bold- 
faced proposition to procure an abortion, in order to 
conceal a crime or an error. The best answer to all 
such requests is — that, by the common law such an 
act is felony, and by the law of God murder ; and that 
it is as lawful to assassinate for them, any other enemy, 
as the innocent object of their cruel designs. I think 
that the persons so situated, and so addressed, will, in 
general, cease to entertain such unlawful intentions, and 
no occasion ought to be missed to urge them not to add 
a new crime to what was probably a misfortune, or a 
grievous error. 



The ovum, however well protected by its situation 
against the operation of any extrinsic causes of destruc- 
tion, is, nevertheless, obnoxious to several that may 
cause its miscarriage. There are also many intrinsic 
causes that tend to effect its death ; for, since the fcetus 
is composed of a structure, and has functions that are 
vastly complicated and mutually dependent, it must be 
liable to disorders that may interrupt its growth, or 
health, and at last cause it to be thrown off as an abor- 
tion. 

The union of the placenta to the surface of the womb 
is so very slight, that it is easily peeled off ; a blow upon 
the region of the womb may destroy its connection, 
and blood be at once effused betwixt the placenta and 
the womb : if a great quantity be effused, the whole 



^jx-^^^H^ 



PREGNANCY. 127 

surface of the placenta may be speedily detached, or 
loosened, and of course, the ovum, now deprived of the 
sources of growth, must perish. A sudden and very 
violent excitement of the blood-vessels, as by surprise, 
anger, &;c. may cause the effusion of blood from the 
placental superficies of the womb ; a contraction of the 
womb may break the connection ; a violent concussion 
of the body, as by falls, jumping, a rude motion in car- 
riages or on horseback, may cause a detachment to take 
place ; the membranes of the ovum may be so weak 
and delicate, as to burst upon very slight compression of 
the womb, as in coughing, straining at stool — upon any 
sudden and powerful exertion, falls, blows, &;c. Thus 
it appears that the abortion may be caused by the death 
of the embryo ; by disease of the secundines ; by sudden 
violent movements of the blood, causing the effusion of 
that fluid behind the placenta ; by direct violence, or by 
the discharge of the water of the amnion. 

If the ovum be ruptured, there is an escape of water 
from the vagina, the quantity of which will depend upon 
the age of the embryo. This is sooner or later followed 
by pain, and a discharge of blood. The pains, which 
are uterine contractions, become more and more frequent 
and considerable, until the remains of the ovum are ex- 
pelled, when the bleeding begins to diminish, and for 
the most part, the pain returns no more. If any cause 
should have been applied that could detach a portion of 
the placenta without rupturing the ovum, many hours, 
or even several days might elapse, before the blood that 
follows the detachment would appear at the orifice of 
the vagina : the blood must force its way betwixt the 
chorion, or decidua, and the surface of the womb ; but 
as soon as it reaches the orifice, it falls into the vagina, 
and then there is what is called a show. If the foetus 
perishes by an internal disease, or in consequence of 
some disorder that happens to seize upon any part of 
the ovum, the further development of the ovum, or of the 
embryo ceases ; it is cast out by the contractions of the 
womb, that sooner or later must supervene. 

In some individuals there seems to be so great an 
irritability of the muscular fibres of the womb, that the 



128 PREGNANCr. 

presence of the conception never fails to bring on their 
contractions before the completion of the term of preg- 
nane}- ; and I apprehend that this excessive irritability 
is among the most common of the causes that produce 
abortions. This view seems to be maintained by a re- 
ference to what happens in those who have already 
miscarried, since such females are found to be greatly 
disposed to miscarry again, at about the same period as 
that at which they had sustained the first misfortune ; 
which appears to me to indicate, that the repeated acci- 
dents of this kind are attributable, rather to an excessive 
or abnormal irritability of the womb, than to any of the 
other circumstances that are enumerated as causative of 
abortions ; for it is far more reasonable, to suppose that 
the same uterus is endowed with too great a degree of 
muscular irritability, than to suppose that several suc- 
cessive germs should be so constituted as to perish always 
at about the same period. 

Whenever the contents of the gravid womb come to 
be expelled from its cavity, that expulsion is effected by 
a real labour, often very severely painful, and requiring 
for its completion many hours of greater or less suffer- 
ing. I have had the medical charge of the same women 
in regular labour and in abortion; and they have informed 
me that, for acuteness and severity of pain, the abortion 
has far exceeded the labour at terra. The reason why 
women suffer so acutely in miscarriages is, that the 
canal of the cervix uteri requires for its dilatation, in the 
early months, a great deal of power to be employed in 
forcing down the embryo, which at that time is contained 
in the cavity of the body and fundus; and the distress 
produced by this dilatation of a long and firm canal is 
very great, and might, a priori, be supposed as great as 
that occasioned by the dilatation of the os uteri, which 
at the last days of pregnancy has become thin and yield- 
ing, whereas, in the early months, the whole cervix, as 
well as the os uteri, are of an almost cartilaginous hard- 
ness and rigidity. 

The quantity of blood lost in some instances of abor- 
tions is enormous, probably on account of the extreme 
degree of uterine irritation which the act of abortion 



PREGNANCY. 129 

developes. The hemorrhage is apt to continue until the 
contents of the womb are expelled ; and it is, therefore, 
highly important to expedite that occurrence by all rea- 
sonable means. Unfortunately these means are few. 
Whenever the flow becomes so considerable as to affect 
the pulse and the complexion of the patient, it is impera- 
tively required that the medical man should ask for an 
examination per vaginam ; and he will sometimes find 
that the ovum is sticking in the cervix, and needs only a 
little aid to escape from it — but, while it remains it can- 
not but keep up the hemorrhage. The fore finger may, 
in such instances, be pushed as far as practicable within 
the canal of the cervix, alongside of the ovum, and 
then bent so as to resemble a blunt crotchet ; by the 
aid of the finger, used in this way, and the assistance 
of powerful bearing down on the part of the woman, the 
offending cause is without much difficulty removed, and 
the effect ceases. When the finger cannot be employed, 
Dr Dewees's placenta-hook answers extremely well in 
some examples, as I have had occasion to experience. 

If, upon making examination, the state of the cervix 
is found to be unfavourable to the speedy expulsion of 
the offending cause, and the hemorrhage be not too 
threatening, recourse may be had to the application of 
napkins, wrung out of cold vinegar and water, to the 
hypogastrium and pudendum ; to the administration of di- 
lute aromatic sulphuric acid ; to the acetate of lead, with 
opium ; or to the preparations of secale cornutum — as the 
powder, in doses of five to ten grains repeated pro re 
nata, or the vinous tincture, of which a teaspoonful 
may be given every half hour, or at intervals of one or 
more hours, accordingly as the events of the case seem 
to demand. The lancet may be resorted to, to aid, both 
in diminishing the hemorrhagic nisus, and in favouring 
the dilatation of the cervix, to which nothing contributes 
more powerfully than venesection. 

But above all the means of putting an end to trouble- 
some hemorrhage, I ought to applaud the tampon, or 
plug. This tampon may be composed of a sponge ; or 
what is far better, of pieces of cotton or linen cloth, 
torn into squares of from two to three inches, which 



130 PREGNANCY. 

may be pressed into the va^na, one at a time, until that 
entire canal is filled and distended with them. They 
should be kept there by a napkin, worn as for the men- 
struse, or by pressure with the hand of a nurse, a napkin 
being- interposed, until the flow is effectually cheeked, at 
least. The tampon may be allowed to remain in situ 
from six to twelve, or even fifteen hours, and when re- 
moved, is generally followed by the ovum, or its re- 
mains, which are frequendy found attached by coagula 
to the upper part of the tampon. Should any dysury be 
caused by its presence, the bladder may be readily re- 
lieved by the catheter, while the woman preserves a 
horizontal posture, which should never give place to a 
vertical one, until all probability of a return of the hemor- 
rhage has disappeared. 

I do not understand how a woman can be permitted 
to die with hemorrhage, in an abortion, while materials 
for a tampon are at hand, since the discharge may al- 
ways be effectually controlled by it. The remedy gives 
no pain, if properly used, and, so far as my experience 
of its employment bears me out, it never causes any 
considerable inconvenience ; while, I may add, it always 
succeeds. 

A good many cases of abortion, in the early stage, as 
from the sixth week to the tenth week, have fallen under 
my notice, in which the uterus was unable to expel the 
remains of the ovum, and in which I could not extract 
it. The female, in such instances, has always recovered 
without the ovum having been visibly discharged ; but 
there always was an excretion, continued for many days, 
of offensive dark coloured grumes and sanies, which I 
accounted for by supposing that the substances in the 
uterus had macerated and come off in a state of semi- 
solution. I think that there is no danger in leaving such 
occurrences in the hands of nature ; and that it is better 
to do so than to reiterate attempts, to extract by force, 
that have perhaps already proved quite vain ; espe- 
cially, considering that there is as great danger of 
exciting inflammation by those attempts, as could be 
anticipated from the gradual maceration of the ovum. 
I am not disposed to deny that the presence of a putre- 



PREGNANCY. 131 

fying substance, even of a small size, in the womb, is 
capable of developing violent inflammation and fever ; 
but it has not happene-i so with me, and I have given 
the same opinion to some medical friends, by whom I 
have been consulted, without the least cause to regret 
having given such advice. Let me be clearly under- 
stood, however, to recommend that the last remainders 
of the ovum should be brought oflf, where it is practica- 
ble by means of any reasonable eflforts. 

I shall not omit the present opportunity for saying, 
with regard to the tampon, that it is not a remedy for 
those cases in which any hope is yet entertained of 
saving the pregnancy. Let us suppose an instance in 
which the placental attachment has taken place at the 
fundus uteri ; that a partial detachment of the placenta 
has happened ; and that the blood, having forced its 
way in a narrow stream, or rivulet, betwixt the womb 
and the outer surface of the ovum, has at length made 
its appearance at the pudendum. Nothing is more 
common than to see such cases of show suppressed by 
venesection, recumbency, an opiate, some elixir of vit- 
riol, or cold lemonade. Siiould any practitioner, anxious 
to promote the formation of a coagulum, and thereby 
stop the eff'usion of blood and save the pregnancy, have 
instant recourse to the tampon, what would be the con- 
sequence ? The blood, instead of escaping externally, 
would be forced back on the ovum, while the newly 
effused portions of it, instead of flowing by the route 
already formed, would contrive to dissect oflf or separate 
the ovum more and more, until the whole of it should be 
detached, and at last come off, enveloped in the centre 
of a compressed clot. To use the tampon, therefore, is 
to insure the abortion ; hence it is only a remedy for 
tlie hemorrhage of abortion, and not a remedy for mis- 
carriage, which it not only cannot prevent, but actually 
insures, or renders certain. The blood wliich continues 
to flow into the womb, after the vagina has been closed 
by the tampon, may be compared to a river dammed 
across its channel, and whose waters, in consequence, 
overflow their banks, drowning the adjacent country. 

With regard to the tampon, I have further to add, that 



132 PREGNANCY. 

its employment in advanced stages of pregnancy, al- 
though allowable in certain instances, demands very great 
discrimination, inasmuch as it is capable of converting 
an open into a concealed hemorrhage, as we shall have 
occasion more fully to remark when we come to the 
consideration of uterine hemorrhage, in labour. It may 
with safety be employed up to the close of the fifth 
month of gestation, as the womb, until that period, 
is incapable of admitting a sufficient quantity of blood to 
give any well grounded fears of a fatal concealed he- 
morrhage ; but at a later stage, the capacity of the uterus 
is so much increased that the tampon, if employed at all, 
ought only to be used while the practitioner himself 
carefully observes its effects, resolving to remove it in 
case the uterine cavity should become distended, and 
filled with either fluid or coagulated blood in a threaten- 
ing amount. I was told, not long since, of an instance in 
which a gentleman, treating a case of hemorrhage after 
delivery, was pressingly called for to visit another wo- 
man in labour, and as he felt compelled to go, he tam- 
poned the vagina with his handkerchief, by which means 
he effectually suppressed the apparent hemorrhage, but, 
upon returning shortly afterwards, found the patient 
dead ; the womb having filled with blood, instead of 
that fluid having escaped at the vulva — ^just such a con- 
clusion to the affair as ought to have been expected from 
the use of the tampon under such circumstances. 

It is commonly thought that women who suffer under 
repeated abortions, are quite as much as, if not fully 
more subject to a consequent prolapsus uteri, than those 
who are confined at full term. The natural tendency of 
labour is to produce a prolapsion of the womb, and that 
tendency must be much greater where the vagina has 
been so much distended and pressed out of its ordinary 
form, than where the vagina has not been so affected. 
But those women who miscarry, are, for the most part, 
not sick any longer than during the actual miscarriage. 
They generally get up, most imprudently, the next day, 
or in some instances even on the same day. The solid 
and weighty substance of the uterus now bears down 
the vagina, to v/hose upper extremity the womb is at- 



PREGNANCY. 133 

tached ; and the vagina, weakened and relaxed by the 
discharges of the miscarriage, makes less resistance 
than is common, so that the womb takes permanently a 
much lower level in the pelvis than it ought to have. 
All the difficulties and embarrassments likely to accrue 
from this vicious situation of the womb, might be obviated 
by a modicum of patience and prudence in the beginning. 
The woman should be told, in plain, but urgent language, 
that too early a getting up exposes her to the great risk 
of having a falling or bearing down of the womb : but 
she feels so well after the abortion, as to be quite un-' 
willing to maintain a recumbent posture more than a day. 



It is very difficult, at least for me, to account in a satis- 
factory manner for some of the symptoms by which pro- 
lapsions of the womb are accompanied. These symptoms 
are, pain in the loins and region of the sacrum, accom- 
panied with a sense of dragging weight, whenever the 
female continues long upon her feet, either in standing 
or walking. There is also, very generally, a pain extend- 
ing from the region of the spleen, or that of the liver, 
down towards the groin — pain, that is very frequently 
maltreated as hepatic or splenic, and sometimes as ne- 
phritic ; particularly where it is accompanied with some 
derangement of the chylopoietic viscera, or with dysuria 
or strangury. 

There is also very frequently to be observed a great 
complaint of tenesmus, and such a sense of pres- 
sure upon the floor of the pelvis, as makes the patient 
think that every thing is coming away from her. The 
belly too is often flatulent and painful, and there is 
aching of the thighs and even of the legs. I repeat that 
I find a difficulty in discovering a rationale for all these 
symptoms. The facts are as follows. The womb is 
attached to the upper end of the vagina, which is a mem- 
branous tube or canal, serving as its ductus eflerens : 
the vagina itself has no power whatever to sustain the 
womb at its proper level in the pelvis ; the weight even of 
the unimpregnated uterus would crush the vagina down, 



134 PREGNANCY. 

were it not that the vagina is held in its proper place by 
the vesico-vaginal and the recto-vaginal septa ; for it is 
not to be conceived that the ligamenta lata have any- 
other eifect than to stay or steady it, and obviate its dis- 
position to fall over on its side, to the right or to the left. 
Suppose the vagina and uterus to descend ; then either 
the bladder and rectum must also descend along with it, 
or else the cellular tissue, which composes the bond of 
tinion or septum, must be put on the stretch, and even 
considerably elongated. The neck of the bladder must, 
by such a teasing influence as this, become, in time, 
considerably imtated, and in that way cause a dysury 
or strangury, which can be removed only by replacing 
the uterus in its proper position, and keeping it there by 
a longrecmnbency, or else by first pushing up the womb. 
and afterwards keeping it up by means of a pessary. 

Considering that a very slight degree of prolapsus uteri 
is capable of bringing on and maintaining the pains in 
the back, one can hardly be induced to suppose that the 
dragging of its vessels and nerves could occasion all the 
disorder ; nevertheless, such disorder disappears imme- 
diately after the uterus is replaced, and if sustained in its 
proper position by a pessary, or by a suitable attitude of 
the patient, does not return. 

I have been accustomed to regard much of the distress 
experienced by females with prolapsus, as belonging to 
the class of neuralgic disorders, and my opinion on this 
point has been, for many years, confirmed by the occur- 
rence of singular cases, to which I had not seen any allu- 
sion in books, until I met with an account of similar cases 
in the recently published work of M. Maunsell, of Dub- 
lin, a work which although small in size, is replete with 
sound doctrine, and rich in numerous and important 
practical details. These cases I have been, for several 
years past, in the habit of relating in my lectures, as 
will be easily recollected by any of my pupils who may 
peruse this page. I have also spoken upon this subject 
before a numerous assemblage at the Philadelphia IMedi- 
cal Society, in the winter of 1833 and 1834. The cases 
to which I allude may be exemplified by the ensuing 
statement. 



PREGNANCY. 135 

On the fifth day of July 1828, 1 was called to see — ■ — 
-, a mulatto woman, in Water street, aged about 



thirty years. She was lying upon her back ; the knees 
were drawn up ; and she was supporting the bedclothes 
witli her hands, lest they should press upon the abdo- 
men, which was so exquisitely tender and sore, that she 
could by no means endure their weight or pressure. 
She had been suffering this pain for many hours, and 
had a short quick respiration, on account of the pain 
which any extensive motion of her diaphragm communi- 
cated to the abdomen, and which made it necessary for 
her to restrain the respiratory movements as much as 
possible. Upon hearing her account of the symptoms, 
witnessing her distress, and observing her decubitus, 
I was at first convinced that she was labouring under 
intense inflammation of the peritoneal coat of the intes- 
tine. The slightest pressure of my hand on the abdo- 
men was resisted with exclamations ; for the part was, 
to the greatest degree, quick and sensitive. 

Upon examining the state of the pulse, which I ex- 
pected to find tense and corded, I was much surprised 
to discover that it was nearly natural, as respected its 
frequency, volume and hardness. The incongruity of 
the signs derived from the examination of the abdo- 
men and of the pulse, led me to make further inquiries. 
She had borne several children, of which the youngest 
was now about a year old. I became convinced that 
her pains were those of prolapsus — a neuralgic state of 
the abdomen, produced and maintained by a misplaced 
womb. In brief, I obtained permission to make an 
examination per vaginam ; and upon pushing up the 
womb, which I found very low down, near the vulva, 
the abdominal pain suddenly ceased, and in a few mi- 
nutes afterwards she could bear, and did bear, without 
shrinking, the rudest pressure of the hand on the abdo- 
men. This was the second instance of this sort of dis- 
order I had met with ; the first one having occurred in a 
young unmarried woman, about two years before. Since 
that period I have seen not less than six similar cases, 
all of which bore, with the exception of the state of the 
pulse, the most striking resemblance to acute peritonitis. 



136 PREGNANCY. 

I feel well assured that instances of disorder of the kind 
just pointed out, can only be properly denominated by 
the title of neural^a with prolapsus uteri. 

There are many cases of prolapsus uteri that require, 
for their cure, only a short confinement to the recum- 
bent posture ; others are so inveterate that a mechanical 
remedy is indispensable, because the tissues which sus- 
tain the womb at its due elevation in the pelvis, when 
once very much altered in their density, do not recover 
until after the lapse of a considerable portion of time. 

The mechanical remedy to which I have alluded is 
called a Pessary. This is an instrument which, being 
introduced within the vagina, and allowed to remain 
therein for several weeks or months, supports the womb 
at its due height in the body, and thus obviates all the 
inconvenience experienced from its prolapsion. Thus 
if a female with prolapsus be suffering ever so severe 
pain, or sense of dragging weight in the pelvic region, 
and the womb be lifted up on the point of the finger 
and sustained there for a short time, the pain and drag- 
ging sensation cease, and do not return until the uterus 
again falls down very low, and begins to excite again 
the neuralgic affections connected with its displacement. 

Pessaries are made of various shapes, and of a great 
variety of materials. Many are made of a piece of cork, 
cut into a proper form, and repeatedly dipped in melted 
wax, until covered with a thick coat of that substance. 
The objection to this kind is, that in the warmth of the 
organs the wax is so much softened that the rough sur- 
face of the cork sometimes becomes uncovered, and then 
irritates the parts with which it is in contact. Others 
are made of the same material that is used for the con- 
struction of elastic catheters and bougies. Others again 
are made of glass, blown by the glass-blower into a con- 
venient size and form. Some are used that consist of sil- 
ver, and others are of silver washed with gold. Of the me- 
tallic pessaries now in use in our American practice, two 
kinds are prepared : one of which is the flat pessary, or 
rather the disk-like pessary, which is concavo-convex, 
with very thick periphery, and a small opening in its 
centre ; the other is a globe of silver, washed with 



PREGNANCY. 137 

gold, so as to prevent the oxidation of the metal. Both 
these pessaries are made of plates of metal, so thin that 
they are sufficiently light ; and as the gilded surface 
admits of a very high polish, they are as little likely to 
irritate the parts they touch, as any foreign body that 
could be constructed. I much prefer the metallic to the 
glass pessary, on account of the greater lightness of the 
former, and on account of its having quite as good a polish. 
It appears to me that a globular pessary is capable of ful- 
filling all the indications that could be possibly collected, 
for a mechanical remedy, in this affection. I prefer it, 
therefore, to all other forms of this instrument; and 
since it cannot become displaced by turning on its axis, 
a fault frequently found with the flat or disk-like pessary, 
I am fully confirmed in my opinion of its superior value. 
I shall take this opportunity to mention that I was, not 
long since, informed that a female labouring under pro- 
lapsion, to a very great degree, made use of the ring of 
a parasol, which having dipped in melted wax until 
sufficiently coated with it, she introduced it herself into 
the vagina, and has worn it for twenty years without her 
husband having, even until this day, the least knowledge 
that she uses such a remedy. It seems that she is un- 
able to dispense with the support that the instrument 
gives her; since, whenever she removes it, the pains, and 
sense of weight or dragging, return immediately. I 
may also mention that another lady, of my acquaintance, 
wore one of the globular form during ten years, without 
removing it once : it has now been dispensed with for 
at least ten years, and her health remains excellent. 

There are certainly many instances to be met with in 
which the pessary fails to effect a cure, probably be- 
cause the relief it yields is so great as to lead the indivi- 
dual to abandon all other precautionary or medical mea- 
sures, feeling that with this resource, a sufficient degree 
of comfort may be obtained. Such a course is, to say the 
least, not just to the patient, nor to the instrument, since 
it should not be expected that the mere reposition of the 
parts could cause them to recover their original firmness 
or density, however it might conduce, with other reme- 
dies, to so desirable an end. It is, notwithstanding, to 

M* 



138 PREGNANCY. 

be said, that if a pessary should, after being properly ad- 
justed, sustain the uterus at its proper level in the exca- 
vation, the pressure of the globe upon the tissues which 
enclose it conld not fail to have a great tendency to con- 
dense those tissues, and thus obviate that relaxation of 
them which constitutes the pathological essence of the 
disorder. I am very certain, from actual observation, that 
this pressure does exert such an influence as I have men- 
tioned ; I have noticed it, particularly in the case of a 
lady from the country, who sent for me a few months 
since, and informed me that she was suffering very much 
from a prolapsus, notwithstanding that she wore a flat 
pessary, w^hich had not been removed for two years. 
Upon withdrawing the instrument, I found that the va- 
gina had firmly contracted upon it, and felt rigid, and hard , 
and shortened, as if moulded upon the pessary. The 
removal of the instrument was followed by the complete 
relief of the patient, who has continued since that time 
to do without one, and not to require one. This hard- 
ening, or condensation of the tissues, from the continued 
contact of a foreign body, is a pathological occurrence 
commonly to be met with, as, for example, in the case 
of a bullet lodged in the tissues, which is soon surrounded 
by a special sac ; and also in the case of a calculus in 
the bladder, which not unfrequently is enclosed more or 
less completely in a sac, which is formed around it in 
consequence of irritation and pressure. 

In order to concur with the restorative action of the 
pessary, the patient ought to avoid the causes that favour 
the production of prolapsus. In an especial manner 
ought she to avoid the injurious influence of constipated 
or overloaded bowels, which, not only by their weight, 
but by inducing a sort of tenesmus, greatly promote 
a descent of the womb. The bowels should, therefore, 
be kept in a soluble condition by small doses of neu- 
tral salts, magnesia, lenitive electuary, milk of sulphur, 
or even w4th rhubarb, taken in the smallest quantities 
that may suffice to produce an aperient eflfect. She 
should avoid all sorts of exercise or occupations that 
might keep her long on her feet ; all violent straining 
eftbrts at lifting : and she should wear no tight dresses, 



PREGNANCY. 139 

especially corsets, which, by narrowing the waist, always 
have the effect of depressing some of the contents of the 
abdomen, that are thus thrust by them down into the 
excavation of the pelvis. 

For the adjustment of the pessary several preliminary 
steps are required, of which I shall now proceed to speak. 
Whenever it is, in any case, probable that the com- 
plaints of the patient depend upon p»olapsion, an exami- 
nation per vaginam ought to be made, in order to deter- 
mine, first, the existence and degree of the disease ; and 
second, the necessity for, and the size of the instrument 
to be employed. Or, if the examination be determined 
upon, it is well for the physician to provide himself with 
at least tv/o pessaries, one of two inches, and one of two 
inches and a quarter in diameter, so that, if necessary, a 
choice of them may be made and the whole operation 
concluded on one occasion, whereby the female is spared 
the disagreeable necessity of a second or third exposure 
to the operation. 

It is, in general, much to be desired that the bowels 
should be opened previously to the introduction of the 
globe, and this object can be attained by an enema, or 
a dose of castor oil properly timed. Attention to this 
point is the more emphatically indicated by the proba- 
bility that the mere presence of that globe in the vagina 
might excite the expulsive action of the rectum, which, 
if possible, ought to be prevented, until a whole day, or 
a day and a half shall have passed : when the expul- 
sive action of the bowels takes place too soon after the 
introduction of the instrument, it is almost always forced 
out of the vagina, and then requires be replaced. 

In order to introduce the pessary, let the patient be 
placed on her left side, with the knees drawn up, near 
the edge or foot of the bed. She ought, of course, to be 
entirely covered with the bedclothes. If the parts be 
found very much constricted, no attempt ought to be 
made to introduce the instrument, until after they shall 
have been somewhat dilated by the insertion of two or 
more fingers of the right hand into the vagina, which 
may be used, at the same time, to draw the perineum and 
end of the vulva downwards and backwards. A gentle 



140 PREGNANCY. 

and patient operation of this sort very soon prepares the 
organs for the final steps of the process, namely the 
introduction of the instrument. 

The pessary should be dipped in a cup of olive oil, or 
it should be smeared with fresh lard, and then pressed 
against the top of the arch of the pubis, and steadily car- 
ried beneath that arch, and then behind and above it, 
until the whole ball has passed above the confines of the 
constrictor vaginae muscle, which is known by all resist- 
ance ceasing. The introduction ought not to take place 
too easily ; for, if only a slight force is required to insert, 
an equally slight force might suffice to expel it — a vexa- 
tious case that always follows an injudicious selection 
of the instrument. 

It is but rarely that I have found it important to push 
up the prolapsed organs, previously to the adjustment. 
The replacing them is as easily effected by the ascent 
of the ball, as by the ends of two fingers, and with less 
pain or discomfort. 

After the operation is concluded, the patient may rise 
and walk a few turns about the room, in order to learn 
whether any change, as to the symptoms, can be ob- 
served, and whether the instrument gives any pain or 
uneasiness ; and if all proves to be right, she ought to 
return to the bed, or lie down upon a couch, for at least 
a day, in order that the parts, by contracting sufficiently, 
may not admit of a procidentia of the pessary itself, or 
in order that the sustaining or supporting office of the 
globe may not be in the least degree counteracted. 

An injection may be daily used for the vagina, to be 
composed of a decoction of red bark and nut-galls, half 
an ounce of each, in powder, to a pint and a half of 
water, to be boiled down to a pint. This injection 
should be thrown in from a common female syringe, 
and should, if possible, be detained at least half a minute 
in contact with the surfaces. 

The instrument ought to be worn for at least three 
months, not requiring to be removed either on account 
of the flow of the catamenia, or on account of cleanliness, 
which is sufficiently provided for by the daily use of the 



PREGNANCY. 141 

injection, and employment of the sponge and a basin of 
cold water. 

After the lapse of three months, the pessary can be 
safely removed, for at least a fortnight, during which 
time the patient ought scrupulously to avoid all the 
causes that tend to produce a bearing down of the womb ; 
such for instance as costiveness, violent exertions, long 
walks, long continuance in a standing position, &:c. &:c. 
The fortnight having passed, the pessary should be 
again adjusted and worn at least one month, during 
which time the injection ought to be repeated once a 
day ; after this the pessary may be again removed for a 
short time, and its application repeated according to the 
necessity of the case. 

In those instances where pregnancy ensues, the symp- 
toms disappear about the period of quickening, and are 
not likely to return until the patient begins to take exer- 
cise after the accouchement. Hence, great care is ne- 
cessary to restrain her from rising too soon from her bed ; 
and, if all such precautions should seem to fail, the pes- 
sary may safely be applied for a month or six weeks ; 
beginning from thirty to forty days after the birth of 
the child. 



In proportion as pregnancy advances, the womb in- 
creases in longitudinal diameter ; so that if it should 
from any cause happen to be turned over backwards, the 
top of the fundus uteri would lodge in the hollow of the 
sacrum, while the os tincae would be pressed upon the 
symphysis of the pubis, or above it. The fact of such a 
displacement being occasionally met with cannot be 
doubted, and the inconveniences and dangers arising 
from it are too numerous to admit of my passing over it 
here without a few remarks. 

Considering that the antero-posterior diameter of the 
pelvic excavation is equal to four and a half inches, it is 
reasonable to suppose that the unimpregnated womb 
cannot readily be caught under the projection of the 
sacrum, even if it be liable to be thrown backwards 



142 PREGNANCY. 

under that promontory. Yet the unimpregnated uterus- 
is liable to be turned over, or retroverted, and retained, 
until the reposition of it be effected by a skilful hand. 
There is no reason to doubt that the uterus is frequently 
turned over backwards, but not retained ; for the urinary 
bladder, when very full of water, extends backwards and 
downwards, pushing the top of the womb along with it. 
If this happen to a woman about two and a half or three 
months gone with chQd, she will scarcely fail to have a 
retroversio uteri. 

Suppose the fundus to be caught and detained under 
the promontory, a&just above mentioned, and that the 
child still proceeds in its growth, carrying with it the 
womb in which it is enclosed ; the consequences are a 
complete impaction of the womb into the excavation— 
a total prevention of the flow of urine, by pressure on 
the urethra — a stoppage of the canal of the rectum — 
severe pressure upon the internal sacral foramina, with 
their nerves ; and unless by timely measures obviated, 
the certain and miserable death of the patient. In the 
case examined by Dr Hunter, so completely impacted, 
or jammed, w^as the womb into the cavity of the pelvis, 
that after the death of the patient it was found imprac- 
ticable to get the womb up out of the excavation, until 
the pubis was cut through with a saw, in order to admit 
of the enlargement of the brim of the pelvis. It is dif- 
ficult to conceive of a situation more frightful than that 
of a patient under such circumstances. 

Most of the instances of retroversion are attributable 
to a distended bladder. The modest delicacy of women 
often compels them to resist the most urgent desire to 
pass off the urine. A female riding in a carriage, or 
placed in such a situation that she cannot withdraw from 
the company without being suspected of a desire to uri- 
nate, will allow the bladder to fill almost to bursting ; 
and if she be pregnant about three months, she will 
scarcely fail to have retroversion of the womb. When 
at last she obtains an opportunity to evacuate the bladder, 
she finds she has a partial or total suppression of urine. 
The usual recourse is had to spirits of nitre, to water- 
melon seed or parsley root tea, and perhaps a dose of 



PREGNANCY. 143 

castor oil may be resorted to ; but as relief can only 
come by some mechanical remedy, the medical man is 
at length, and reluctantly, sent for. 

To see a healthy looking woman seized with complete 
suppression of urine, without having been before the 
subject of any urinary ailment, is warrant enough for us 
to suspect a retroversion of the womb, especially if the 
patient be at the time pregnant, and not advanced be- 
yond the fourth month. The symptoms of which such 
patients complain are either total suppression, a stillici- 
dium, or great dysury ; with pains about the region of 
the pubis and sacrum, with great tenesmus, or bearing 
down, and a sense of obstruction or stoppage in the 
rectum. 

No case like this ought to be suffered to pass without 
making an examination per vaginam. For this purpose 
let the patient lie on her back, near the right side of the 
bed ; the feet drawn up near to the breech ; the head and 
shoulders raised with pillows. The physician should 
stand by the bed side, and with his left hand placed upon 
the hypogastrium, ascertain if the bladder be much dis- 
tended : it will sometimes be felt almost as high up as 
the umbilicus. The forefinger of the right hand may 
next be carried into the vagina, in order to seek for the 
OS tincae, which is to be found behind the symphysis 
pubis, or even thrust over and above it : the vagina 
seems to be obstructed by a hard body, which is the bas- 
fond of the womb, whose fundus is turned down into the 
hollow of the sacrum, and jammed into the cul de sac, 
composed of the reflection of the peritoneum, which lines 
the upper half of the vagina and the front of the rectum. 

Having thus verified the existence of a retroversion, 
the next steps required to be taken are those that are 
demanded for the repositing the womb. Among the 
most pressing indications of cure, is the relief of the sup- 
pression of urine, which in general is easily fulfilled by 
the introduction of the catheter, which should be a male 
catheter, composed of the French elastic material. A long 
one is the best, because the womb, in changing its own 
position, carries up the neck of the bladder, and thus 
elongates the urethra so very considerably, that it will 



144 PREGNANCY. 

be found convenient to use a long instrument for the 
evacuation of the water. 

Inasmuch as the most ordinary cause of retroversions 
is a distended bladder, it has been thought that the re- 
moval of this distension is the best remedy, it being 
supposed that the uterus would recover its attitude as 
soon as the pressure which overset it should be taken 
off. Indeed there are cases in which the restoration 
takes place soon after the bladder becomes emptied. It 
has also been contended that a sound discretion indicates 
the propriety of leaving the case in nature's care, after 
this preliminary measure has been accomplished, lest 
by any rude or too persevering attempts to replace the 
womb, the ovum might suffer so much injury as to bring 
on an abortion. I admit that I am not prepared to de- 
cide as to the necessity for such great prudence, since 
I have only on one occasion put it to the test : and on 
that occasion I drew off the urine two successive days, 
the accumulation being very great; and then finding 
that the malposition was not rectified, I was compel- 
led to replace the womb with my hand : no inconve- 
nience whatever followed the operation, although the 
patient was near four months complete, gone with child. 
In a subsequent pregnancy, the same person suffered 
a retroversion of the womb, nearly at the same period ; 
and when I was called to see her, I immediately proceeded 
to restore it to the proper attitude. In this case also 
the pregnancy was not in the least interrupted. 

Having succeeded in drawing off the water, the pa- 
tient, if necessary, should have a copious enema, ia 
order to unload the rectum, which, if replete with foecal 
matters, might offer considerable obstacles to the suc- 
cess of our attempt. In the next place we ought to 
endeavour to raise the fundus, by pressing the bas-fond 
of the womb, which can be felt through the under sur- 
face of the vagina, upwards, so as to lift the whole mass 
in a direction parallel with the axis of the brim. The 
cervix uteri is tied to the more anterior parts of the pel- 
vis by the vagina and the vesico-vaginal septum, so that 
if we carry the mass considerably upwards, it must be 
by tilting the fundus ia that direction. Attempts of this 



PREGNANCY. 145 

kind will not always suffice. Where they fail, a finger 
may be passed into the rectum, the forefinger of the left 
hand, if the woman is on her left side, and of the right 
hand if she be upon her back. Before the finger has 
passed very far, it meets with the fundus uteri, which 
presses upon the canal of the intestine ; in this situation 
we have far more power to move the womb than when 
the effort is made only from the vagina. Pushing gently 
and steadily upwards, we find the mass gradually to 
recede, and at length the fundus, liberated from its re- 
straint, suddenly emerges, with a sort of jerk, from 
under the promontory, from which instant the woman is 
cured. 

I have sometimes failed of success, until I placed the 
patient in a more favourable attitude ; one in which she 
could not bear down, and thus oppose the success of my 
measures. I have directed that she should turn on her 
face ; then draw her knees up under her until the thighs 
were in a vertical position, giving to the pelvis the 
highest possible elevation : the face was to be placed on 
the bed without pillows, and the point of the thorax was 
also to be touching the bed. Lying in this posture, the 
effect of mere gravity might suffice, in time, to unhitch 
the fundus uteri from beneath the promontory ; since all 
tenesmus and bearing down are arrested. After waiting 
a short space, until the effects of the position were se- 
cured, I have pushed up the fundus very easily, by acting 
either through the vagina or the rectum. 

A woman who has just recovered from a retroversion 
ought to lie in bed two or three days, and should never 
be left more than six or eight hours without evacuating 
the bladder, spontaneously or by the catheter, lest that 
organ, filling again, should unhappily a second time 
depress the fundus, and thus cause us to lose all our 
trouble for want of a moderate precaution. 

The gravid womb, doubtless, becomes in four months 
and a half too large to admit of the occurrence of retro- 
version : but the accident may occur at any period short 
of it ; it may take place not only in the non gravid, but 
in the virgin uterus. 

On the 22d of February 1828 I was called to visit 

N 



146 PREGNANCY. 

Elizabeth B., aged about twenty years. She has com- 
plained for several months past of dragging- pain in 
the left side of the abdomen, with a sense of weight 
and great uneasiness within the pelvis. Has menstru- 
ated regularly. For the last three weeks has been per- 
secuted with constantly repeated and painful desire to 
go on the stool ; with symptoms of strangury, or dysury, 
amounting often to stillicidium urinae. After a careful 
inquiry into the history of her case, I informed her of 
the nature of my diagnosis ; and she at length agreed to 
permit an examination by the touch, as I assured her 
that I had no means of relief for her, if there were really a 
retroversion, short of the touch. In this painful neces- 
sity she submitted, with a laudable unwillingness, to the 
operation, and it was with no little difficulty that I at 
length carried the finger beyond a remarkably strong 
hymen into the vagina. The os uteri was found near 
the symphysis of the pubis, and the fundus was disco- 
vered overturned into the peritoneal cul de sac. After 
a long perseverance in endeavouring to raise the fundus, 
I was compelled to attempt it with the forefinger of the 
left hand passed into the rectum, by which method I 
pushed the uterus up ; whereupon she immediately de- 
clared that she was fully relieved of the sense of weight 
and pain that had so long been tormenting her. She 
continued well from that moment. I consider this as a 
case of considerable interest, inasmuch as it proves the 
possibility of a long continued retroversion of the womb 
in the non gravid state of that organ. 

The accident of retroversion may be considered se- 
rious or dangerous, just in proportion as it occurs at a 
more advanced period of pregnancy ; for according as 
the pregnancy is of an older date, is the necessity 
greater for a speedy reposition of the organ. I have, I 
think, pointed out sufficiently at length, the dangers to 
be apprehended from a retroversion continued until the 
whole mass becomes so impacted into the excavation, 
as to render its extrication, without abortion, impossible. 
As I have met, as yet, with no example in which it was 
impossible to replace the organ, I do not feel it incumbent 
upon me, at this time, to do more than refer to the severer 



PREGNANCY. 147 

methods of extricating the woman : which are, first, the 
artificial rupture of the amniotic sac, which, by allowing 
the water to escape, reduces the size of the womb so 
much as to enable the operator to succeed in restoring 
it to its proper position ; or lastly, the puncture of the 
womb itself, when it is found impossible to pass a bou- 
gie into the os uteri. 



I have witnessed several accouchements in females 
reduced to the last degree of weakness and emaciation by 
pulmonary consumption. In these cases I have not 
found that the child partook of the debility and cachexy 
of the unhappy mother. In one case that fell under my 
care the patient laboured under laryngeal consumption, 
and was to the last degree emaciated and feeble, notwith- 
standing which, her pregnancy held out until the com- 
pletion of her term, which she survived only four or 
five days. Her child was excessively fat, weighing 
above ten pounds; and has continued to enjoy excellent 
health up to the present time, when it is between five 
and six years of age. These instances convince me 
that no methods that have yet been discovered can serve 
to prevent the development of the child, and thus cause 
the woman to suffer less in her accouchement than she 
would do if her child were to be small. 

Notwithstanding that I think no means are within our 
reach of procuring easy labour by retarding the growth 
of the child, I am far from abandoning all precautions as 
regards the mother herself. A woman about to suffer 
the peril and pangs of childbirth should be prepared for 
the crisis by a course of dietetic treatment, to commence 
a few weeks before her term, and by an occasional vene- 
section, and the use of a gentle aperient that may serve 
to secure the regular evacuation of the bowels. The 
diet need not be rigorous, but it should exclude, for the 
last eight or ten days, all meats and butter, and highly 
seasoned food. The bleedings should be small, and 
repeated two or three times, from the seventh to the ninth 
month. A neutral salt, calc. magnesia, or sulphur, are 



148 PREGNANCY. 

the best of the aperients for the purpose now under con- 
sideration. Gentle exercise, in walking or riding, ought 
not to be neglected by those who desire to promote the 
heathful performance of the great vital functions, and to 
prepare them for the struggles of labour, or for a firm 
resistance to the shock that the constitution often suffers 
by delivery. I have met with a good many instances of 
severe suffering during or after labour, that I supposed 
justly attributable to the inordinate indulgence of the 
appetite in the latter weeks of pregnancy. 



CHAPTER X. 



LABOUR 



In Midwifery, the term Labour expresses the whole 
series of phenomena that attend the birth of a child. 
Labour is the process by which the contents of the gravid 
womb are expelled ; and the word is highly expressive 
of the violent and painful struggles and efforts, of the 
woman, to overcome the obstacles to her deliverance 
from the burthen which she has so long borne. It 
should commence, as we have already seen, at or about 
the two hundred and eightieth day from the last appear- 
ance of the menses, or the one hundred and fortieth day 
after quickening; and may, in general, be expected to ter- 
minate without any artificial power or assistance, after a 
few hours of travail — the time being greater or less, ac- 
cording to the amount of the power capable of being 
employed, or the resistance that is destined to be over- 
come. 

The essential element of labour is the contraction of 
the muscular fibres of the womb, the end or object of 
which is the evacuation of the uterine cavity, so that, 
the whole of its contents being ejected, it may return 
again to the non gravid state, when it will measure from 
two and a half to three inches in length, about an inch 
and a half in width, and half an inch or three quarters 
of an inch in thickness ; the organ being, before the 
commencement of contraction, about twelve inches long 
bv seven or eight inches in transverse diameter. 

N* 



150 LABOUR. 

As the OS uteri is closed during pregnancy, it follows 
that the expulsion of the contents of the organ cannot 
take place until the orifice is sufficiently opened to per- 
mit the child to pass out ; and that there is also required 
for the purpose, a sufficient dilatation of the vagina, and 
of the vulva, in all which parts a greater or lesser de- 
gree of resistance or obstacle is found ; which, taken 
in connexion with the resistance affijrded by the bony 
structures, are generally the causes of a delay of several 
hours in the birth of the child, even where it presents 
itself most favourably to the openings through which it 
is destined to effect its exit. 

In a vast majority of cases, the powers of the womb, 
alone, are insufficient to effect the delivery of the child; 
and its birth is aided very considerably by the efforts of 
the abdominal muscles, and the diaphragm, which are 
not only capable of making a direct expulsive effort, but 
also, by presenting a point d'appui for the contracting 
womb, can enable it more efficiently to exert its own 
peculiar forces. The abdominal muscles, acting alone, 
can push the point of the womb down low into the 
excavation, and hold or fix it there, while the fundus 
and body of the organ propel the ovum against the ob- 
stacles that stand in the way of its escape. Hence, 
although the essential element of labour consists in the 
uterine contractions, there are collateral elements of the 
process that greatly avail in its completion, and that 
ought always to be well understood, in order that they 
may be either called into action, or restrained, as the 
obstetrician may please to direct. 



The cause of labour, or I should rather say the cause 
of the onset of labour, is not well understood ; although 
it is quite probable that it is to be found only in the ina- 
bility of the womb, in any given case, to bear further 
distension. Labour begins from a necessity of the ute- 
rine constitution, and not from any ascertained degree of 
development of the child, which, whether large or small, 
is most likely to be born two hundred and eighty days 



LABOUR. 151 

after the last catamenial period of the mother ; but it 
may not be born until three hundred or even more days 
have elapsed ; and the size of the child is not found to 
bear a proportion to the excess of the duration of the 
pregnancy. It does in fact, frequently occur, that the 
womb begins its contractile effort long before the expira- 
tion of the tV70 hundred and eighty days ; or, on the other 
hand, fails to commence its contraction for several days 
after the two hundred and eighty have elapsed ; but, 
whenever it does begin, it is because it will admit of no 
further or longer continued distension. 

The theory by which Baudelocque endeavours to ac- 
count for it is, that there is a contest or antagonization be- 
twixt the fibres of the cervix and those of the fundus and 
body of the womb ; that in the early part of pregnancy, the 
fibres of the body and fundus yield to, while those of the 
cervix resist the distending force, until about the seventh 
month, at which time they also begin to yield, and con- 
tinue to yield until the end of the ninth month ; these fibres 
of the cervix may be regarded as the seats of the reten- 
tive, while those of the fundus and body are the seats of 
the expulsive faculty or power ; at the ninth month 
they are balanced, or antagonize each other exactly. At 
length, those of the fundus become the more powerful, 
and the cervix and os uteri are dilated, and finally so 
completely opened as to allow the ovum to escape. 
This explanation is, perhaps, as good as any that could 
be offered ; but, although human sagacity or reason may 
remain ever incompetent to the task of unfolding the 
secret operations on which the commencement of labour, 
or the completion of utero-gestation depends, it is per- 
haps not unworthy of remark, that, in the development 
of the gravid uterus and its contents, we behold a won- 
derful adaptation of parts to the purposes they are 
destined to fulfil; since the growth of the child would, if 
continued, make its delivery impossible, and therefore 
the Author of nature has, by a simple law, provided 
against such a fatal contingency ; the womb, by that law, 
refusing to yield any further than is suflnicient to allow 
the child to acquire a certain degree of magnitude and 



152 LABOUR. 

vigour, essential for its respiratory life, but not too con- 
siderable to prevent its birth from taking place. 

The term of utero-gestation and the commencement of 
labour are also fixed, and rendered necessary by the great 
distension of the abdominal muscles, and the pressure 
upon, and displacement of the parts contained v^ithin the 
abdomen. 1 know not what influence, on the production 
or excitement of labour, may be exercised by the altered 
state of the abdominal muscles themselves, but it is per- 
haps not too much to infer, that, they do at length exert 
some considerable share of influence, by their constant 
or tonic contractile operation, in aiding the fundus and 
body to overcome the retentive effort of the os uteri, 
any yielding or relaxation of which tends to invite or 
provoke the contractile effort of the fundus. We see, 
at least, that, in the last days of pregnancy, the womb 
settles down with its apex in the excavation, and the 
woman seems much smaller than she w^as before this 
sinking downwards of the uterine globe was perceived : 
now it may be asked, what can cause this settling or 
sinking downwards of the womb, if it be not either the 
action of the abdominal muscles and diaphragm, which 
have pushed it downwards, or the contraction of the 
womb itself ? It is probable that both of these influences 
are, sometimes, concerned in the matter ; and at other 
times only one of them, and either of them ; for it hap- 
pens that when- the womb is much sunken, it in one 
case feels very hard and firm, as if its fibres were in a 
state of contraction or condensation, whereas in another 
case it is soft and flaccid, notwithstanding it may be very 
much depressed into the excavation ; in either example, 
no sign of actual labour being present. The sinking 
downwards of the womb takes place, in some persons, 
several days before the first pains are felt. In such 
cases it must generally be regarded as wholly passive in 
the matter ; it is forced down by the muscles, and not 
by any intrinsic action, or power of its own. 

The contractions of the womb take place at intervals, 
which are long at the beginning, but grow shorter as the 
labour advances. They last from fifteen to thirty or 
forty seconds, and on many occasions, even longer. 



LABOUR. 153 

The intervals, at first, are from twenty to thirty minutes ; 
but as the irritation becomes more intense, the pains are 
repeated every five, three, and two minutes, and even 
every minute ; increasing in violence and duration until 
the organ is freed from its load. 

The pain felt in labour, is owing to the sensibility of 
the resisting, and not to that of the expelling organs. 
Thus the sharp, agonizing, and dispiriting pains of the 
commencement of the process, which are called grind- 
ers, or grinding pains, are surely caused by the stretch- 
ing of the parts that compose the cervix and os uteri. 
They are not felt, except rarely, in the fundus and body 
of the organ ; and nineteen out of twenty women, if 
asked where the pain is, will reply that it is at the lower 
part of the abdomen, and in the back ; indicating, with 
their hands, a situation corresponding to the brim of the 
pelvis, and not higher than that — a place corresponding 
to that of the os uteri. 

When the pains of dilatation are completed, and the 
foetal presentation begins to press open the vagina, the 
pain will, of course, be felt there, and is at length referred 
to the lower end of the rectum, and the sacral region 
generally. The last pains, which push out the perine- 
um and put the labia on the stretch, will of course be felt 
in those parts chiefly. The painful sensation, under 
these circumstances, is represented as absolutely inde- 
scribable, and as comparable to no other pain. 

The efiect of the pain on the bladder and rectum 
might easily be foreseen ; and even where it fails to 
excite the sympathetic action of those parts, the de- 
scent of the foetal head, which sometimes fills up the 
pelvic canal, as a cylinder is filled by its piston, must 
cause the evacuation of the entire contents of the lower 
rectum. 

The effects produced by the pains and efforts of la- 
bour upon the constitution are very striking. The mind, 
in the beginning, is anxious, irritable, fearful, and full 
of the most gloomy anticipations ; but as the process 
goes on, and the expulsive efforts become more and 
more violent, it acquires courage and firmness and the 
most dogged resolution. The patient seems like one 



154 LABOUR. 

uho has a task set for her, which she is resolved to 
execute as rapidly as possible, and she bears the great 
pains of expulsion far more submissively, or rather cou- 
rageously, than the small or dilating pains. The ac- 
tions of the woman indicate pretty clearly, to the prac- 
tised eye, the state of advancement of the foetus. 
Antecedently to its exit from the os uteri, or its deep 
insertion into that circle, the voluntary efforts of the 
patient are confined to a violent grasping of things with 
her hands. She generally seizes the hand of a by- 
stander, and squeezes it very violently, or endeavours to 
twist or wring it. Such an action always indicates a 
grinder, or a pain of dilatation, but when an expulsive 
force takes place she not only grasps with all her force, 
but she pulls at any thing in her reach ; so that an ex- 
perienced accoucheur generally can decide, upon enter- 
ing the chamber, during a pain, that the dilatation is or 
is not completed, by observing whether the patient 
merely squeezes or presses the hands of her assistants, 
or, on the other hand, whether she pulls ttiem with great 
violence. 

In addition to the signs derived from the woman's 
actions, the practitioner can frequently decide upon the 
degree of forwardness of the labour, by attending to the 
nature of his patient's expressions and moans, and her 
respiration. In the dilating pains she either gives out 
her breath freely, or merely holds it, making use of no 
straining or bearing-down effort, and even if she be 
requested to strain or bear down, as if at stool, she will 
resist, or cannot obey the injunction. On the other hand, 
when the os uteri is nearly or quite opened, and the 
expulsive pains alone operate, she not only holds her 
breath, but she makes use of the muscles of respiration 
to fix the thorax firmly, and then, in the most forcible 
manner, contracts the muscles of the abdomen upon the 
womb. If she be enjoined to desist from bearing down, 
she often fails to obey the injunction, because the tenes- 
mus, like that of dysentery, is irresistible. The muscles 
that she employs in bearing down, after she has fixed 
the diaphragm and other muscles belonging to respira- 
tion, are the rectus abdominis, the external and internal 



LABOUR. 155 

obiiqni, and the transversalis. Now it will be seen, 
upon the slightest advertence, that while the fundus uteri 
is high up in the abdomen, the violent contraction of 
these muscles would have but little effect in forcing the 
uterus downwards, for it w^ould merely compress the 
womb against the back part of the abdomen ; but on the 
other hand, when the uterine globe has sunk low down in 
the belly, that the operation ofthese abdominal muscles, as 
agents of expulsion, must become very great and cogent. 
I have ever found it useless to urge a woman to bear 
down upon a grinding pain, and always feel it incum- 
bent upon me to cause the nurses and bystanders to de- 
sist from exhorting the patient to bear down, in the early 
stages of labour, an exhortation which they very kindly, 
but very untimely, never fail to make. Such voluntary 
efforts cannot be beneficial in their influence on the 
labour, but they may become pernicious, in certain cir- 
cumstances, where they not only tend to disorder the 
sanguine circulation, but very much and very early help 
to exhaust the strength. 

Even leaving out of question the exciting effects of 
the pangs and agonies of travail, we should naturally 
expect that the muscular exertions of the parturient sub- 
ject would greatly accelerate the circulation of the blood, 
and augment its momentum ; and we accordingly find 
that the pulse grows more and more elevated as the 
efforts become greater and greater ; the heart beats with 
gieat violence, and the pulsations amount to one hun- 
dred and upwards in the minute ; the respiration be- 
comes hurried in proportion, and of course the heat of 
the body tends to be developed, pari passu, with the cir- 
culation and respiration ; so that fever would soon be- 
come intense, were it not that the most profuse diapho- 
resis, chiefly from the upper part of the body and head, 
comes on, to prevent the occurrence of what would, 
otherwise, become a dangerous fever. I have already 
taken occasion to remark upon this excited state of the 
vascular system, that it is not to be deprecated except in 
those instances in which it goes beyond the just bounds ; 
it is, however, always worthy of close observation, in 
order that its tendency to excess may be checked, by 



156 LABOUR. 

a free use of cooling drinks ; by ventilation ; by lighten- 
ing the bed clothes ; by making the patient comfortable 
in her bed ; removing wet sheets and heated pillows ; 
by an enema, or purge ; and lastly and chiefly, by the 
use of the lancet. The state of the mind is also worthy 
of a large share of the accoucheur's regard. The most 
cheering and satisfactory assurances that the state of 
the labour will admit of, should be given, with a due 
observance of the truth. A woman will be more com- 
forted and composed by being made certain that she 
shall be delivered in six hours, than by a promise which 
she does not fully believe, that half an hour more shall 
put a period to her anguish. 

The signs of labour are those which we obtain from 
simply observing her manner, and from hearing her own 
account of her symptoms ; or they are such as we ob- 
tain from the touch, or examination per vciginam. In 
general, we are accustomed to note, by a watch, the length 
of the intervals betwixt the pains, and to form an opinion 
of their intensity, by the gestures or moans, or other 
complaint of the woman. If the patient have reached 
her full term, we are commonly free to announce from 
these points of diagnosis, that labour is begun ; and if, 
upon making examination per vaginam, we find the os 
uteri dilated ever so little, and the membranes rendered 
tense during the pains, we may be quite sure that the partu- 
rient process hath commenced. The application also of 
the hand to the abdomen discovers during each pain a 
hardness and rigidity of the uterine globe, that gives 
place to a flaccid and yielding softness during the ab- 
sence of the pain. Such are the true pains of labour. 

There are a sort of pains that afflict some women to- 
wards the end of pregnancy, which, however severe they 
may be, and unbearable, are nevertheless very justly 
denominated/«/5e pains. 

I have many times been kept out of my house all night 
in order to be near a patient supposed to be in labour, 
and been refused the privilege of making examination until 
morning, when after so tardy an admission of my request, 
I have found in the morning an os uteri perfecth^ closed, 
and a stili tubulated or cylindrical cervix. So that I 



LABOUR. 157 

have been obliged to announce, not only that the patient 
was not in labour, but, that she had not yet reached the 
full term of pregnancy, by ten days or a fortnight. 

It is exceedingly vexatious thus to be baffled by the 
unreasonable backwardness of the patient to submit 
to an operation which she knows to be necessary and 
inevitable ; but, we shall in all early stages of labour, 
except those where the water comes off at the very com- 
mencement, be liable to such disappointment and decep- 
tion, until we verify our other inferences by the infallible 
method of touching. 

The similarity of these false pains to the true pains, 
of labour is very great ; there is even to be felt the 
hardening of the abdomen : but, if carefully examined, 
it will be found that the rigidity is occasioned by a con- 
traction, not of the womb itself, but of the muscles of 
the abdomen, that are so constricted upon the uterine 
tumour as to make even the womb appear to be con- 
tracted, whereas it is actually only compressed. False 
pains, then, are essentially, involuntary contractions of 
the abdominal muscles. They are, probably, of the nature 
of tenesmus, and are caused either by the irritation pro- 
duced by the distended womb, or by intestinal irritation 
from sordes, flatus, acidity, and other causes that would 
also suffice, in the non gravid state, to bring on spasms of 
the abdominal muscles. The difference between those of 
the non gravid, and those of the gravid state, is, that in 
the former they are paroxysmal, but in the latter they are 
regularly periodical, which latter character they acquire 
from some law that I am unable to explain. 

The regular manner in which labour pains recur, has 
long been the subject of curious speculation. I have not 
found any writer whose explanation of this periodicity 
t^atisfies me, and shall not repeat here for my reader the 
mere hypotheses which I reject myself. It is enough to 
state that the contractions increase in frequency and 
power in proportion as the uterus grows small, or ap- 
proaches more nearly to the moment of excluding its gra- 
vid contents ; a most singular phenomenon, which of itself 
is almost sufficient to refute all the existing hypotheses 
as to the anatomical arrangement and composition of the 
o 



158 LABOUR. 

muscular texture of the organ. The observation, how* 
ever, is perfectly true. In the contraction of the muscles 
of locomotion or relation, we find that the greatest power 
of the organ is excited at a point mid-way between elon- 
gation and the greatest condensation. Thus the biceps 
acts with greatest force when the arm is bent to a right 
angle, and not when it has drawn the hand up to touch 
the clavicle, or when the arm is fully extended ; but in 
the case of the uterine fibres, if we adopt the common 
theories, we must admit that the nearer the extremes of 
the muscular fibres are brought to each other, the stronger 
do they act. In the case of the uterine fibres, what- 
ever be the cause of the first contractions, or whatever 
be that of the periodical return of them, both the causes 
seem to acquire strength by exertion. The weakest 
pains are those which are met with in women who have 
the womb enormously distended with water, or with 
twins ; the uterus in such cases seeming to be distended 
beyond the just limit, and to lose thereby, its tonic or con- 
tractile force, a case similar to that which is observed in 
an over distended bladder, which, as is well known, re- 
fuses to act upon its contents, so that, even with the 
catheter introduced, it is sometimes necessary for the 
physician to aid the bladder by pressing his hand strong- 
ly upon the hypogastrium. 

The indisposition to energetic movement in a womb 
too greatly distended by an excessive quantity of liquor 
amnii, or by double pregnancy, is for the most part ob- 
viateol by early rupturing the ovum, and allowing the 
waters to run off" ; but even by this practice we cannot 
always remove a certain lentor or apathy of the womb, 
which embarrasses the labour very much, nor prevent a 
troublesome hemorrhage after delivery, the consequence 
of that lentor : the womb is, like the bladder, when once 
overstrained by distension, exceedingly prone to relax 
and fill, and become over distended again ; it is inert — 
atonic. 



When, by the contractions of the fundus and corpus 
uteri, the child's head hath been forced partially into the 



LABOUR. 159 

vagina, or through the os uteri, the tenesmus or straining 
with the auxiliary or abdominal muscles begins, and as 
I have already mentioned, the whole womb, with its 
contents, is pushed downwards ; under these circum- 
stances, the circle of the os uteri descends very low in 
the excavation, and its anterior lip may be felt, stretched 
behind and across the pubic arch, a little below its 
crown : but as soon as the mouth of the womb is fully 
opened, and the head completely lodged in the vagina, 
the lip of the womb ascends, probably, quite to the top of 
the pelvis in front, and as high as the projection of the 
sacrum behind — the os uteri encircling the throat of the 
foetus with a gentle or moderate contraction. At this 
stage of the labour, the fundus uteri approaches much 
nearer the os uteri — nearer by at least four inches, or four 
and a half, perhaps. When the head escapes from the 
vulva, the thorax of the child takes its place in the va- 
gina, and at last, as the thorax emerges, the abdomen 
and lower extremities succeed it in that place, so that 
nothing now remains in the womb but the placenta and 
membranes, with a few ounces of blood and water, 
and the fundus is not more than five inches from the 
OS uteri, instead of twelve inches, as it was at the begin- 
ning of labour. The womb is strongly contracted for 
the last expulsive throe ; and if the placenta were not 
detached, even earlier than this, it could scarcely retain 
its connection with the uterine surface, now that its 
superficies is so greatly reduced in size. In fact we do 
find, in a large majority of cases, that the placenta is 
pushed wholly or in part into the vagina, by the same 
pain that forced the abdomen and breech to take that 
situation; or if it be not thrust out of the womb, it lies 
loose and detached within the cavity of that organ, and 
ready to be expelled upon the slightest renewal of con- 
traction, or even by the voluntary expulsive effort of the 
abdominal or auxiliary muscles. Instances do occur, of 
a morbid adhesion of the placenta to the womb, in which 
it is not detached, even for some time after the birth of 
the child ; and I think I have noticed that where the at- 
tachment exists at the anterior part of the cavity, it is 
less apt to be thrown off by the same pains that expel 
the child. The constringing movement at the fundus is 



160 LABOUR. 

greater than at the front or back of the womb ; hence, a 
placenta attached to the fundus, is more likely to come 
off well, than one seated on another part of the cavity. 

The separation of the placenta is commonly followed 
by an effusion of blood. This effusion is inconsiderable 
in proportion as the action that condenses the uterine 
tissue, is more energetic and stable. It is supposed that 
nearly all, if not all, the blood that comes off, flows from 
what was the placental surface of the womb. Now, as 
the placenta is from fifteen to twenty inches in circum- 
ference, it will occupy a space equal to such a circle, on 
the womb, before labour begins ; but when the womb has 
contracted so as to be no bigger than two fists, the pla- 
cental surface of it must be not more than one and a half 
or two inches in diameter, so that the effusion from 
its vessels is greatly checked, and, in very tonic uteri, 
wholly suppressed for a time. If in any case the toni- 
city ceases to exist, then the womb expands again more or 
less, and blood begins to flow. It is desirable, therefore, 
after delivery to have a well contracted womb. 

During the whole of this process of parturition, the 
child is quite passive ; if alive, its body possesses a cer- 
tain degree of firmness and solidity (wanting in the dead 
foetus) that enables the womb to force it downwards, and 
cause it to dilate the parts it is destined to pass through : 
it does not assist itself; as indeed it could not do, with 
its thighs flexed upon the belly, and the legs crossed per- 
haps upon the epigastrium, and pinioned by the coats of 
the womb, which press it together into a compact and 
passive mass. 



At the beginning of labour, the womb acts only upon 
the ovum en masse ; the lower point of the chorion 
is pressed like a bag into the os tincae, and protrudes 
through it and is often burst, and the waters are dis- 
charged, before the fundus of the womb comes to press 
firmly on the child's breech, and to push it downwards. 
But whenever the fundus uteri does begin to impel the 
child downwards, it can only do so by acting on the 
pelvic extremity of the spinal column. The cephalic or 



iacM 



LABOUR. 161 

cervical extremity of this column, of course, resists the 
force, and the spine becomes more arched. It is as if one 
end of a bow were rested on the floor, and the hand rest- 
ing on the upper end should press it directly downwards 
in order to bend the bow. The outward thrust of the 
arch is in this case so great, that the cervical end of the 
spinal arch, attached as it is at the condyles of the occi- 
pital bone of the child, will naturally thrust backwards 
and thus raise the vertex and depress the chin ; or I should 
rather say (as the head is downwards), it will depress 
the vertex and raise the chin, or force it towards the 
infant's breast. This happens the more readily, as the 
child's head lies over the pelvic opening, which, so to 
speak, yawns to receive it. 

This bending of the neck, or carrying the chin to the 
breast, is a most important act in the history of a labour ; 
it is called the flexion of the head ^ and when it takes 
place in due degree, enables the head to descend into the 
pelvis with very little obstruction ; for another change, 
called the rotation of the head, does not take place well 
if this first step fails. 

I shall beg leave to repeat here some parts of the ob- 
servations I have made in Chapter II., when speaking 
of the fcEtal head. 

The head of a child at term passes very easily into 
and through a well formed pelvis, provided it present 
certain of its diameters only to the canal. Now the 
diameter extending from the child's chin to its vertex is 
five inches — or five and a half in many children ; but the 
outlet of the pelvis is nowhere more than four and a 
half inches, at most ; of course, the child could not be 
born should it present such a diameter. Again, the di- 
ameter extending from the vertex to the space between 
the eyebrows, is fully four inches, and often more than 
that ; but from one ischial tuberosity to the other, is but 
four inches, so that were this cephalic diameter of four 
inches to be parallel with this bis-ischiatic diameter of 
four inches, the head would stop, it could not descend 
any farther. The vertical diameter of the head is how- 
ever only three inches and a half, which is smaller than 
any one of the pelvic diameters, so that no great obstruc- 



I &Z LABOUR. 

tion can, in any natural labour, be offered by the bones, 
provided the chin be, early in the process, borne strongly 
against the breast, so as to make the vertex descend, and 
cause a considerable dip of the horizontal diameter of 
the foetal cranium, 

The promontory of the sacrum, as may be seen upon 
referring to the cut, juts into the superior strait in such 
a manner as to turn any rounded body off, either to its 
right or left side, and accordingly, it rarely happens that 
either the forehead or the vertex can pass down imme- 
diately in front of the promontory ; but, as there is a 
concavity on each side of it, the vertex, or the forehead, 
passes down in this concavity, which gives to the head 
an oblique direction. The forehead, in a majority of 
instances, goes to the right of the promontory, or in 
front of the right sacro-iliac symphysis, while the vertex 
descends below the brim, opposite to the left acetabulum ; 
not at a fixed point, but either nearer the front of the 
pelvis, or more posteriorly, as the case may be ; indeed, 
the child generally is found to bore with its head, so as 
to turn the vertex now forwards and now backwards, 
until it becomes fixed in one position at last, by getting 
under the arch of the pubis. So common is it to observe 
the child to descend with the vertex opposite to the left 
acetabulum, that that is taken or counted as the first 
position of a vertex presentation ; and Baudelocque, 
whose authority is followed, on this subject, in the 
United States, enumerates a second, third, fourth, fifth 
and sixth position, the enumeration or order being 
founded on the relative frequency of the several sorts, 
as they are to be met with in practice. Thus the most 
frequent, according to Baudelocque, is the first position, 
in which the vertex is directed to the left acetabulum, 
and the forehead to the right sacro-iliac symphysis ; next, 
the second position, in which the vertex is to the right ace- 
tabulum, and the forehead to the left sacro-iliac symphy- 
sis ; the third position, in which the vertex is t)ehind the 
pubis and the forehead in front of the promontory ; the 
fourth position, where we find the vertex at the right 
sacro-iliac symphysis and the forehead towards the left 
acetabulum ; the fifth position, in which the vertex is at 
the left sacro-iliac symphysis and the forehead to the 
right acetabulum ; and lastly the sixth position, where 




162 



L 



LABOUR. 



163 



the vertex is at the promontory and the forehead at the 
symphysis pubis. 

It is doubtless extremely convenient and proper to 
reduce all the possible modes of vertex presentations to 
a small, yet sufficiently comprehensive classification : but 
the reader, and especially the young student, should re- 
member that all these classifications are human inventions ; 
they are the proposita or the dogmata of different men ; 
and that, in fact, it is possible for any part of the head 
to present itself at any part of the brim. If he should 
further find any difficulty in remembering the order, or 
application of these several positions, let him make use 
of such an arrangement as the following, which I have, 
for several years, been in the habit of offering to my 
class, in my lectures on Midwifery. Beginning with 
the vertex at the left acetabulum, let him say, vertex 
left, vertex right, vertex front ; forehead left, forehead 
right, forehead front. I think this is as easy a nomen- 
clature as the other to remember, and as it explains its 
own meaning, it is also, on that account, a better one. 
The following table, taken from Madame Boivin*s Me- 
morial sur I'Art des Accoucheurs, shows the proportional 
frequency of these several positions, as observed by that 
author. I have it to remark, however, that the average 
of vertex-left cases is smaller, in my practice, than that 
found in this table ; but as I intend to offer some fuller 
remarks on that point, I feel compelled to defer them to 
a subsequent page, it being necessary now to proceed 
with my account of the mutations suffered by the head 
of the child, during labour. 

In the birth of twenty thousand five hundred and 
seventeen children, there occurred nineteen thousand 
five hundred and eighty-four vertex presentations, of 
which there were 

15,693 in the 1st position, 
3,682 ... 2d 



6 

109 

92 

2 



3d . 

4th. 
5th. 
6th. 



19,584. 



164 LABOUR. 

Let the head enter the pelvis obliqtiely, the vertex 
being in the first, or vertex-left position — it is not to be 
understood that the dip of the horizontal diameter of the 
head will carry the posterior fontanel into the centre of 
the pelvic canal, on the contrary, such a dip would be 
too great — and the vertex, or posterior fontanel, glides 
down along the ischium, repelled by that bone, and directed 
by its inclined plane inwards and forwards ; so that it 
describes a spiral line in its descent, and the vertex, which 
on entering the upper strait was directed to the left, 
is, without any change of posture of the child's body, 
turned near a quarter or a sixth of a circle, to bring it 
under the arch of the pubis, beneath which it extends 
itself again, recovering from its first flexion, so as to 
allow the crown of the head, the forehead, the face, and 
last of all, the chin, to roll out, in succession, from the 
floor of the vagina and edge of the perineum. These 
three mutations are the most important in the mechan- 
ism of labour : first, the flexion ; second, the rotation ; 
and third, the extension of the head. The regular suc- 
cession of these several states is necessary to an easy 
natural labour ; and the principal business of the medi- 
cal attendant, in such labours, is to see to it that they 
occur in due order and time. 

As to any person's being able to explain the mechan- 
ism of the pelvis, or its operation in parturition, without 
the aid of the subject, either recent or dried, I hold it to 
be an impossibility. Let the student, therefore, who 
wishes to comprehend this matter, which involves proba- 
bly the most important information that he will have occa- 
sion for in obstetric practice— let him take a dried pelvis 
and a festal cranium, each well and naturally proportioned 
to the other — let him plunge the cranium into the excava- 
tion, holding it in the first position, but without flexion; 
he will find that it cannot descend very far, on account 
of the rapid approach of the inclined planes of the ischia 
below ; but if he now turns the vertex somewhat down- 
wards, or brings the chin upwards, it will descend a 
little further. As he presses it downwards, the same 
inclined plane of the ischium tends to repel and deflect 
it towards the pubic arch, in which direction no resist- 




165 



LABOUR. 165 

ance is offered ; if it glance upon the obturator mem- 
brane, and indent it, the resiliency of that tissue is suffi- 
cient to repel it still more, and still more to deflect it 
towards the front ; in fact, it naturally takes a pivot or 
rotatory movement, which is greatly enhanced or pro- 
moted by the structure of the back and lateral parts of 
the pelvic excavation, which are so inclined as to repel 
and deflect the forehead, and cause it to fall into the 
hollow of the sacrum. Let this experiment be tried 
both with the dip or flexion, and without it, and it will 
be seen that in the first case the rotation is almost spon- 
taneous, and in the last very difficult, if not impossible, 
without extrinsic aid. 

The rotation being completed, the vertex is found 
jutting forth under the arch of the pubis ; it emerges 
more and more, until the occiput, or upper part of the 
nucha is pressed against the crown of the arch — the 
further progress of this part ceases — it becomes a fixed 
point, or an axis, on which the head, as before said, 
turns or rolls out from the orifice of the vagina, at the 
close of which evolution the extension of the head is 
complete. 

After the head is born, the face turns again to the side 
of the pelvis, towards which it was directed at the be- 
ginning of labour, or before rotation, and that is called 
its act of restitution. 

While the head is undergoing these mutations, the 
shoulders of the child are entering the basin. In the 
first position, the vertex is to the left acetabulum, and 
the right shoulder to the right acetabulum, and the left 
one to the left sacro-iliac junction. As the shoulders 
descend, the right one rotates towards the arch of the 
pubis, and the other falls into the hollow of the sacrum ; 
the thorax is now plunged deep into the excavation, 
where its further progress is arrested by the floor of the 
pelvis. A renewal of the uterine effort forces the left 
shoulder to glide off from the apex of the sacrum and 
coccyx, and displace the perineum, which it thrusts 
backwards, until the shoulder is born ; the arm and hand 
are delivered, and retire so far backwards as to allow the 
right shoulder to disengage itself under the crown of the 
pubic arch ; and the body of the child immediately after- 



166 LABOUR. 

wards is expelled with great violence, occasioned by the 
irresistible tenesmus that the woman experiences in this 
stage, and which compels her to bear down with her 
whole energy. 

A repose of eight or ten minutes follows the birth of 
the child, and a slight pain, or a voluntary bearingdown, 
expels the placenta and membranes, as before said. 

The almost supernatural exertions and struggles of the 
woman, as well as the painful sensations she experiences, 
and the novel impressions made upon the nervous sys- 
tem by the successive stages and occurrences of parturi- 
tion, have brought about a violent excitement of the 
nervous and circulatory systems of the economy: the 
former of which is resolved by cries of joy, by tears, 
and by the delightful sense of security, of finished toil, 
and the gushing tenderness which the mother feels for 
her newly born and helpless progeny ; the latter rapidly 
abates, under the effusion of blood, in greater or less 
abundance, and the abstraction of the stimulus of exer- 
tion, pain and dismay. The flood of perspiration gradu- 
ally subsides, and a short sleep, the best " restorer," 
soon permits the patient to feel " comfortable," a phrase 
peculiarly adapted to the case of a puerperal woman. 
The lochias flow in such abundance as to require five or 
six napkins to imbibe the blood eflfused during the first 
twenty-four hours, after which they decrease in quantity, 
and grow pale, until by the tenth or fifteenth day, many 
ladies have none but a whitish discharge, which also 
ceases between the twentieth and thirtieth day. 

On the day after delivery the globe of the uterus 
appears to be larger than it was immediately after the 
discharge of the placenta ; it can generally be felt in the 
hypogastrium from six to ten days, after which it re- 
treats into the recesses of the pelvis, diminishing daily 
in size, until, by the end of the month, it is nearly as 
small as before it was gravid. 

Such is the history of Labour, in general terms, 
which, though it may perhaps afibrd a pretty good coup 
d'oeil of the phenomena by which it is characterized, is 
not sufficiently in detail for the purposes of this work ; 
on which account I shall proceed to treat of other parti- 
culars in the ensuing pages. 



CHAPTER XI. 



CONDUCT OF A LABOUR. 



The conduct of a Labour comprises the whole manage- 
ment of a parturient patient, from the first beginning of 
her pains, until the complete exclusion of the secundines ; 
and it ought also to include all that is done for the secu- 
rity of the mother and the child, during the period im- 
mediately ensuing the birth. As labours are extremely 
various in their characters, as to duration, pain, facility 
or difficulty, the title at the head of this chapter is an 
important one, and fruitful of topics, which, if properly 
handled, could not fail to prove interesting and instruc- 
tive to whatsoever reader might desire, under such a 
head, to seek for useful, and indeed I might say, indis- 
pensable information. 

Any person meriting the name of obstetrician may be 
supposed competent to the conduct of a natural labour, 
where the series of phenomena proceeds with rapidity, 
and in a perfectly natural order of succession and dura- 
tion, provided he will remember the oft repeated adage, 
" a meddlesome midwifery is bad ;" and be, therefore, 
willing to abstain from impertinent interferences. A 
kindly providence has so ordered this painful office of 
parturition, that the accoucheur, in most cases, hath 
really nothing to do except to receive and protect the 
child, and attend to the delivery of the after birth, ex- 
tending his care to the disposal of both the mother and 
her offspring for the first few hours after the termination 



168 CONDUCT OF A LABOUR. 

of the labour. To show what the proportional number of 
unassisted or natural labours is, to those that require the 
aid of science or skill, I may state that out of twenty thou- 
sand five hundred and seventeen children born at the 
Hospital de la Maternite, for the time under the care 
of Madame Boivin, only three hundred and thirty-four 
required to be assisted, leaving twenty thousand one hun- 
dred and eighty-three children that came into the world 
by the natural powers dedicated to the office of parturi- 
tion. The time required for the completion of the pro- 
cess of childbirth, may be learned from the following 
little table taken from Dr Maunsell's Dublin Practice of 
Midwifery, 1834. Dr M. states that in eight hundred and 
thirty-nine cases occurring at the Wellesley Institution, 

347 terminated in 6 hours, 
300 



87 . 


. . 18 


52 . 


. 24 


37 . 


. 48 


3 . 


. . 56 


5 . 


. . 60 


1 . 


. 72 



Although it will appear from the foregoing statements 
that women generally are found capable of helping them- 
selves, yet every labour is not a natural one, nor is every 
natural one an easy one ; and, where the deviation is at 
all considerable, much reflection and prudence are re- 
quired in order to prevent a natural labour from becoming 
laborious, difficult, or actually preternatural. Were it 
so that all the cases of parturition should end favourably, 
and pass easily, there would, certainly, be no occasion 
for medical interference, and we might lay down our 
vocation and take up a less disagreeable one : but the 
facts happen not so : hence, when it is protracted through 
many successive hours of apparently fruitless suffering, 
the sufferer loudly claims that something should be done 
for her relief, and compels the medical attendant to em- 
ploy such arguments and exhortations as may serve to 
reassure and compose her, or else adopt some real or pre- 
tended measures for relief, or for accelerating the birth. 



CONDUCT OF A LABOUR. 169 

That practitioner confers a real benefit on his patient, 
who, by a proper degree of candour, or the evident pos- 
session of confidence in his own knowledge or skill, 
cither convinces the patient that the time is not at hand for 
intervention, or that, when the time shall arrive, all the 
needful judgment and dexterity will be employed for her 
security, A woman may utterly fail of all her courage 
and firmness, and so, by falling into a despairing or 
fretful humour, greatly retard and embarrass the partu- 
rient processes, to that extent, indeed, as to render some 
manual operation necessary, merely because she has lost 
faith and trust in her attendant ; whereas she shall recover 
a great, and indeed a sufficient degree of power, imme- 
diately upon the appearance of some other person either 
celebrated for his professional abilities, or exhibiting in 
countenance and manner the evidences of confidence in 
himself, and in the resources of his art. The young 
practitioner, who sometimes permits his own disap- 
pointment to affect, in any degree, his remarks or his 
gestures, exerts a very injurious influence upon his pa- 
tient. He ought under all circumstances to retain a 
perfect command over his feelings ; and, above all, to be 
in full possession of the most accurate theoretic know- 
ledge, at least of the processes about to be perfected, and 
of the measures that are indicated in their several stages, 
whether they occur in the natural order and manner, or 
whether any thing arise to interfere with or obstruct 
them. Such a practitioner will rarely lose the confi- 
dence of his patient, no matter how severe or protracted 
her sufferings may be. He will support her spirits and 
hopes with his steady and confident assurances of relief 
in due time, and thus prevent the mischief that ensues, 
where the mind, distracted with pain, fatigue and dis- 
mal fears, carries disorder into all the functions of the 
body. Nothing conduces more commonly to the pro- 
duction of the very uncomfortable state of things, now 
alluded to, than the making of rash promises or prog- 
nostics. No one can know beforehand when a labour 
shall be terminated. If the first stages proceed ever so 
favourably, the latter may give the greatest possible 
trouble, and any failure of a prognostic cannot but di- 
p 



170 CONDUCT OF A LABOUR. 

minish the woman's reliance upon the ability of her at- 
tendant. No good practitioner makes them. Let the 
student of midwifery, therefore, early resolve to avoid 
all the difficulties which arise from such great impru- 
dence. 



Few women go through labour without a very great 
acceleration of the pulse, and increase of its force and 
volume. This excitement is sometimes attended with 
the development of nervous symptoms, in such a de- 
gree as to require measures for its diminution. When 
carried to a certain extent, an increased activity of the 
circulation is very advantageous ; it developes in the ner- 
vous system, both cerebral and ganglionic, a vast increase 
of energy which is acknowledged and responded to by 
every part of the constitution, particularly the circulatory 
system, and serves to hasten the arrival of the happy 
moment of release, by augmenting the expulsive ener- 
gies of the womb, to the vigorous and regular contrac- 
tions of which, a somewhat elevated state of the vital 
forces seems requisite in almost all cases. It should not 
be interfered with, then, except under peculiar circum- 
stances : as, for instance, where it occasions severe head- 
ach, mental excitement verging towards delirium, or 
tremors and irregular action of the muscles, carried to an 
unsafe extent. The excess of excitement ought to be 
removed in such cases : in order to prevent it from pass- 
ing into debility and exhaustion, the constant results of 
a great excess of it ; and more especially, to obviate the 
danger of convulsions, apoplexy, and other accidents to 
which the human constitution is obnoxious under vie* 
lent excitements or efforts. I have in a great many in- 
stances observed, that the pains have fallen, or become 
irregular and spasmodic, in consequence of this consti- 
tutional irritation, and that they have recovered their 
vigour and co-ordination by removing the excess of bed- 
clothes, bathing the hands, face and throat with cool 
water, and by the exhibition of cooling drinks, together 
with free ventilation of the apartment. In cases where 



CONDUCT OF A LABOUR. 171 

these would not suffice, I have scarcely failed to re-es- 
tablish the regular course of events by taking blood from 
the arm. 

Notwithstanding that most women have a very greatly 
increased frequency and force of the pulse, during the 
more active stages of labour, it is not universally the 
case ; some females passing through the whole process 
without any change whatever in the rate of the circula- 
tion. 

The following case was under my care on the 9th of 
February 1828. Mrs B. aged twenty-five years, in la- 
bour with her first child, was attacked with the pains at 
seven o'clock A. M., and was delivered at twelve o'clock 
of a healthy female infant. The whole amount of blood 
discharged at the separation of the ovum did not exceed 
three ounces. The pulse was very slow throughout the 
labour, not exceeding sixty-Jive pulsations per minute, 
even during the most violent expulsive pains. Some 
time after the complete expulsion of the secundines, the 
OS uteri was two inches in diameter, and hard and smooth 
as a ring of ivory. 

I could cite many cases from my practice in which 
the pulse was quite unaffected throughout the whole 
process of parturition. 

Professor Dewees has been justly celebrated for the 
boldness and good judgment with which he has resorted 
to venesection, in some cases of labour. The quantity 
drawn by him, in instances which he has reported, al- 
though, doubdess, fully demanded by the exigences of 
the time, and justified by the results, may, nevertheless, 
have induced some persons of lesser powers of discrimi- 
nation, to resort to a similar mode and extent of deple- 
tion ; hence it is not uncommon to hear of very large 
bleedings, of thirty or forty ounces at a time, during 
labour. I must aver, that I think such very large ab- 
stractions of blood not often necessary, and would, 
therefore, take this opportunity to warn the reader to 
discriminate carefully, in making up his judgment con- 
cerning the quantity to be drawn in each particular case. 
For example, where the woman has become too much 
excited, as to her circulation, in the manner above pointed 



172 CONDUCT or a labour. 

out, I have no idea that it is necessary to draw away a 
great quantity of blood. Let him not bleed, then, to use 
a very common phrase, until the pulse is soft. He does 
not want a soft pulse. la labour, or at least in the vio- 
lent stages of labour, the pulse ought to be full, vigorous, 
and somewhat accelerated. If he bleeds, then, till the 
pulse becomes soft, he will substitute for a state of ex- 
citement and excessive power, one of debility and loose- 
ness, quite as much to be deprecated. 

The design of venesection, in the instances I at pre- 
sent propose, is to take off the strain — to mitigate the 
general stimulation which ensues upon too rapid a revo- 
lution of the blood. I therefore think that it is better, 
for the most part, to limit our bleedings, for these ge- 
neral purposes, to something under, rather than beyond 
sixteen ounces. But, on the other hand, where symp- 
toms, strongly threatening, of apoplexy, convulsions, 
pulmonary hemorrhage, inflammation, &;c. make their 
appearance, the lancet shiould be used in the most fear- 
less manner. The same is true of those cases where a 
great relaxation of the tone of the tissues is required for 
some special and pressing object, such as the relaxation 
of a strictured vagina, of a very rigid uterus, the removal 
of a violent congestive or inflammatory accumulation of 
blood in the brain, <&>e. <&&. 



It is difficult to conceive of an individual who, when 
under high excitement, whether from fever or other 
causes, doth not experience a considerable diminution 
of that excitement, upon the operation of an aperient or 
cathartic medicine. 

The facility and promptitude with which the alvine 
discharge can be efiected by means of enemata, renders 
a resort to them of very common occurrence ; and, in 
fact, where only a slight reduction of excitement is 
wanted, they answer the end proposed very fully ; yet 
a dose of some neutral salt, of magnesia, or castor oil, 
may be beneficially administered, in instances where 
there is a promise of suflficient time for the alvine ope- 



CONDUCT OF A LABOUR. 178 

ration to take place before the delivery of the child. 
Aperient doses are the more evidently indicated, in la- 
bour, because it cannot be doubted that the constitutional 
disorder brought on by the pain and fatigue of labour, 
must, in some measure, extend to the digestive organs : 
nothing is more common than to meet with parturient 
patients who vomit very much ; while water brash, heart- 
burn, and sour eructations are also exceedingly common, 
and often quite distressing. 

The foregoing remarks tend to show not only that 
medicines of an aperient kind are frequently indicated 
in obstinate and protracted labours, but they also show 
that great care is required as to the exhibition of food to 
such patients. Some food is wanted, particularly for 
those whose pains are of the lingering kind, and allow 
the process to remain unfinished for many hours. For 
the most part, tea, bread or gruel, sago, &c. are what is 
found to suit the patient best. The best drinks are gum- 
water, toast-water, lemonade, cold water, and such arti- 
cles as these ; the object here, being to sustain the system 
by means of nutriment, while under severe effort, at the 
same time that we carefully avoid calling that effort in 
the direction of the digestive organs. The whole powers 
of the economy should, therefore, be husbanded and pre- 
served, in, as much as possible, their normal condition, 
in order that they may be directed and determined to- 
wards the womb and its auxiliary organs. In the case 
of a very slow labour, which should be unattended with 
constitutional symptoms, or any evidences of gastric dis- 
order, a liglu broth, or even some small portions of very 
digestible meat, might, upon due reflection, be allowed 
to the patient. 



The attitude of the patient exercises, in many cir- 
cumstances, a notable influence on the progress of labour. 
It is the almost universal custom, in this country and in 
England, to direct the woman to lie upon her left side, 
with the knees drawn up ; a posture which is highly con- 
venient, and productive of the least possible exposure, 
p* 



174 CONDUCT OF A LABOUR. 

But where the labour proceeds slowly, the heat and 
the pressure occasioned by lying still, under such cir- 
cumstances, are highly injurious. The woman ought, 
therefore, to be directed to turn on her back, or even 
on to the opposite side, or to rise and sit in an easy 
chair, from time to time. I do not recommend that they 
should be too much urged upon this point; but I remark, 
that the influence of custom is so great, that a proposition 
to turn on the back is not unfrequently received here, 
with something like astonishment and aversion by the 
bystanders, who seem to regard that attitude as one of 
indelicacy, at the least. Hence it is proper to assign 
reasons for the request. 

In cases where the retardation arises from an improper 
direction of the expulsive forces, it is of the highest im- 
portance to direct the patient as to her attitude. For ex- 
ample, if a lateral limb of the os uteri can be felt towards 
the middle of the pelvis, and the other one is either out 
of reach of the finger, or very high up on the side of the 
ischium, it will be found that the fundus uteri is directed 
to one side of the abdomen, giving more or less obli- 
quity to the long axis of the womb, and of course an 
oblique line of direction to its forces, which are decom- 
posed, or partially nullified thereby. 

On Sunday, November 30th, 1828, I was sent for to 
visit Mrs C, whom I found lying upon her right side. 
The pains seemed so expulsive, that when I arrived, I 
expected to receive the child immediately, for she bore 
down like one in the last throes of labour. I requested 
her to turn upon the left side, informing her that that 
position was the most convenient for me. She did so. 
The pains now became inefficient, and partook, in appear- 
ance, of the character of the grinding pains. I found that 
the uterus had obliqued far down to the left side, as soon 
as she turned over, which interfered with the due exer- 
cise of its power. She was again placed on the right side, 
which brought the womb into its proper line of direc- 
tion, and the labour ended, after three or four pains. 
The same consequences follow from an anterior obliquity 
of the axis of the uterus ; but in this case the anterior 
limb, or lip of the womb, seems to hold the head as in a 



CONDUCT OF A LABOUR. 175 

sling, the anterior ridge of the orifice being stretched 
across the head, quite towards the middle of the pelvis ; 
whereas the posterior edge of the circle either cannot be 
felt at all, or is felt high up towards the promontory of 
the sacrum. It is evident, that in such a state of things, 
a good deal of power must be lost, in pushing away the 
anterior part of the cervix, which should be preserved, 
or more usefully employed in other efforts. We are 
advised, in order to remove the difficulty, to draw the 
OS uteri forwards towards the symphysis, and retain it 
there by the fingers ; but there is a rudeness and vio- 
lence in this plan, which will be easily understood by 
such as shall make the attempt, and who, moreover, will 
often find that they cannot retain it in the desirable 
place, without exerting so much force as to expose the os 
uteri to contusion or rupture. If the woman lies on her 
back, the fundus uteri will retire towards the spine, 
bringing its axis into the proper range ; and of course the 
plane of the os uteri will take its proper station : a child 
will, in some instances, be delivered much sooner if this 
precaution be taken, than if it be omitted. 

When we meet with patients who allow themselves 
to be violently agitated by the pains of labour, so as to 
require actually to be held, at a period when the perine- 
um is in danger of rupture (and women are now and 
then so distressed as to lose all command of themselves), 
the best attitude is the one on the back, with the knees 
drawn up : in this position they are kept much stiller 
and quieter than when on the side. I had a woman 
under my care in November 1833, who actually was so 
violent that two or three women could not keep her still; 
when I caused her to assume the dorsal position, she 
became passive enough. 

I have spoken, in another place, of the dip of the occi- 
pito-frontal diameter of the foetal head ; the nearer to 
the middle of the excavation we find the posterior fon- 
tanel, the greater is that dip. But where the fontanel is 
found quite up towards the side of the pelvis, and the 
anterior fontanel is at the same time within reach of the 
finger, we may feel assured that the dip has not taken 
place, and the retardation of the labour may safely be 



176 CONDUCT OF A LABOUR. 

attributed to that cause. Could we, under such circum- 
stances, get the vertex down, or more towards the centre 
of the pelvis, the pains would be more successful. Now, 
as the edges of the parietal bones over-ride the edge of 
the occipital bone, they form a ledge which gives a good 
purchase for two fingers, which, when applied upon that 
ledge, are generally enabled to draw the vertex down- 
wards to the required position. Whenever this opera- 
tion is to be attempted, it should be tried during the ab- 
sence of the pains ; and when the vertex is once pulled 
downwards, it ought to be retained in its place until a 
new pain comes on, and thus enables the operator to 
secure whatever advantage he has gained. Should the 
head be placed, by this gentle method, in the desired 
attitude, it as as easy to conceive, as it is indeed common 
to witness, the increased facilities it affords for the de- 
livery. 

I have always found it much easier to pull the vertex 
down than to push the forehead up, because the finger, 
acting upon the ledge above described, does in reality 
act upon the longer end of the lever, of which the atlas 
represents the fulcrum ; whereas, in an attempt to push up 
the forehead, so situated, the lever we use is very short, 
its real extremity would be the chin ; but we cannot 
reach that part ; moreover, when we attempt any strong 
force, the bones of the os frontis are so yielding, that they 
are readily indented, and we are obliged to desist for 
fear of contusing the brain ; the fingers, in fact, being 
applied near the upper edge of the os frontis, where the 
ossification is as yet very incomplete. The same ob- 
jection does not hold as regards the posterior edges of 
the parietalia, and os occipitis, which are very firm before 
birth. 



The labour may be retarded by the failure of the head 
to undergo rotation. It is sometimes very difficult, at 
the bedside, to learn wherefore the head does not rotate, 
in a patient, who, in another labour, meets with no such 



CONDUCT OF A LABOUR. 177 

difficulty. I am aware that it frequently arises from 
failure of the dip above spoken of; but I wish now to 
speak of a case in which the head has sunk very low, 
where the dip is good, but yet the rotation fails. I have 
on many occasions, after much doubt and anxiety upon 
this subject, found that it could be fully accounted for, 
by referring to the grasp of the cervix uteri, which ac- 
tually bound and held the head so firmly, that it was 
unable to execute its pivot motion. The remedy, in 
such cases, is patience ; for as soon as all resistance of 
the cervix is given up, in consequence of the fatigue of 
the parts, or the acquisition of a perfect dilatability, the 
pains push the head down, and the inclined planes of 
the pelvis cause it to execute its spiral or rotatory move- 
ment in the most rapid manner. 

In all the cases where the rotation fails for want of 
the requisite dip, or approach of the chin to the breast, 
let that want be supplied by pulling down the vertex as 
directed. It must be admitted that such gentle measures 
will not succeed always, but we have, then, the power- 
ful resource of the whole hand, which may be introduced 
into the vagina, and taking the head in its palm and fin- 
gers, can place the vertex wherever it may be desirable 
to fix it. It should be remembered, however, that a 
vectis is, very rarely, but imperatively, demanded for 
the management of such a case. 

The obliquity of the womb, which can, by vitiating 
the direction in which its forces act, greatly retard the 
progress of a labour, may also be a cause of failure both 
of the dip and the rotation of the head. Suppose the 
breech of the child to lie very low down in the right 
flank of the patient ; if the vertex be to the left side of 
the pelvis the dip will be very difficult to effect, and the 
rotation in consequence must fail. The remedy is to 
correct the obliquity by changing the position of the 
woman. It is easy to conceive, that if the vertex remain 
directed still to the left, and the breech could be now 
thrown far down to the left, the dip would be very much 
facilitated. I have on many occasions reaped the benefit 
of attending to this point. 



178 CONDUCT OF A LABOUR. 



The head has sunk low into the excavation ; the fon- 
tanel is in the proper position, neither too near to, nor too 
far from the symphysis : but it advances not at all ; pain 
after pain passes over, with grreat suffering to the mother, 
and yet with no sensible advance of the head. What 
can occasion the retardation ? The finger passes up 
behind the symphysis to the superior strait, and moves 
along the linea ileo-pectinea, a considerable distance, 
showing conclusively that no disproportion exists be- 
tween the head and the bony canal it is destined to tra- 
verse. All uneasiness of mind on the practitioner's part, 
will cease as soon as he discovers that the cervix uteri, 
which he had thought to be sufficiently dilated to offer 
no farther considerable opposition, has ceased for a time 
to yield, and takes hold of the head during every pain, in 
such a manner as to prevent the parietal protuberances 
from escaping into the vagina. The proper remedy here, 
also, is patience ; a small venesection ; a large draught 
of some warm relaxing fluid ; the fortunate occurrence 
of nausea ; a careful adjustment of the axis of the ute- 
rus, and of that of the pelvis ; or perhaps a few very 
powerful exertions of the auxiliary muscles, in bearing 
down, to which the woman can be exhorted. I have often, 
after allowing myself to get into a fret relative to the 
slow progress of affairs, found all my uneasiness dissi- 
pated by a more careful examination ; thus, as above, 
clearly ascertaining that no other than soft obstruction 
existed ; whereas, from too careless an examination, I had 
been erroneously led to believe that the os uteri had 
mounted upon the parietal protuberances of the fcetal 
head, and that some unknown cause of retardation eX' 
isted. 



The hollow of the sacrum is the essential cause of the 
specific properties of the excavation. Those properties 
will be present in perfection, where the sacrum is per- 



CONDUCT OF A LABOUR. 179 

fectly well formed and adjusted : but the sacrum may 
be either too little curved or too much so. I have spe- 
cimens of both kinds of deviation. Inasmuch as the 
rotation of the head requires, for its regular and easy 
performance, a good curve in the sacrum, it is striking, 
that a very straight sacrum must offer considerable im- 
pediments to that important act. Hence, a sacrum with 
too little curve, will protract the period of delivery ; and 
in fact, a case might arise, and such a one has arisen, 
where no rotation at all could take place, but where the 
delivery, at last, must occur without this important part 
of the mechanism of labour — the vertex coming out un- 
der the tuber ischii : a case requiring the very extremest 
degree of flexion of the head. Let the student reflect a 
moment, and he will perceive what process must be sub- 
stituted for the rotation. The occipito-bregmatic diame- 
ter is but three and a half inches, but the tubera ischii 
are four inches apart ; hence, where the rotation fails, 
there must occur a greater dip, causing the occipital fon- 
tanel to take a position nearly in the centre of the pelvic 
canal, by which the relations of size between the head 
and pelvis are restored, and the occipital bone is enabled 
to pass out under the ischium, and the parietal protube- 
rance under the pubal arch. Such a great degree of 
dip may be greatly promoted by the help of the fingers, 
as before stated, but it will take time. It is not very 
difficult when the head is of a medium size. 

On the other hand, if the sacrum be too much curved, 
its apex will jut forwards towards the pubis, so as to 
form a sort of shelf, on which the head lies, the expul* 
sive forces being, for a long time, vainly expended in 
impelling the head down upon this shelf or ledge. The 
gradual compression of the cranium, however, at length 
moulds it into the requisite form, and allows it to slide 
off" the ledge, and the delivery takes place. It is to be 
understood, that very aggravated degrees of this vicious 
conformation involve the necessity of direct interference, 
with some one of the various instruments employed in 
obstetric operations. 

When the pubal arch is not low, but retains the 
character of early life or of the male pelvis, it happens 



180 CONDUCT OF A LABOUR. 

that great retardation takes place i because the act of 
extension of the head cannot take place in due time. 
Such a narrow arched pelvis compels the head to con- 
tinue its descent much longer than one where the arch 
is broad and low. It has as bad an effect as, and indeed 
it is equivalent to, a long symphysis pubis ; for in the 
ordinary conformation, as soon as the occipital bone can 
come to apply itself to the arch, the vertex begins to rise ; 
extension of the head takes place ; the perineum requires 
no inordinate degree of protrusion : but, imagine a pubic 
symphysis of two and a half inches, instead of one of an 
inch and a half, and it is plain that the perineum must 
go farther down before the head can escape under the 
arch. A patient with a very narrow arch has been un- 
der my care in two of her labours, in which the natural 
pains being insufficient, I was compelled to augment 
them by the ergotic stimulation. By violent efforts of 
the womb and abdominal muscles, she gave birth in both 
cases to living children. I need not say, in self defence, 
that I waited as long as I deemed it prudent to do so, 
but my confidence in her strength was vain in each in- 
stance. 

The resistance of the perineum and vulva are so great, 
in many women, as seriously to retard the delivery. I 
have waited six hours by the bedside, after the vertex 
has begun to jut out between the labia, the patient all 
the while suffering severe labour pains, which vainly 
tended to expel the head. In such cases there is no- 
thing to be done but wait patiently, after having placed 
the patient's constitution in its proper attitude, by means 
of venesection; by the least fatiguing posture of the 
body ; by the application of mucilaginous fomentations 
to the genital region ; by the exhibition of relaxing 
drinks, and by the warm bath. I consider that we have 
no right to apply a force, additional to one that nature 
furnishes, and which it is evident must be effective if left 
to itself. Under such perverse resistance of the soft 
parts, time is required to enable them to acquire a yield- 
ing temper. To force the head through them by the 
ergot or the forceps, would be to incur the hazard ol 
shocking lacerations of the external organs of generation, 





ifin 



CONDUCT OF A LABOUR. 181 

or even of the womb itself, which it is rashness, in the 
highest degree, to stimulate and lash into fury, in cases 
where the uterine contractions are already very power- 
ful, and where they would soon effect the delivery, were 
it not that the external parts are unprepared to admit of 
it. The true principle of practice here is, to diminish 
the resistance, and not to increase the power, already 
perhaps excessive, and therein dangerous. Let me be 
fully understood as referring, in the above remarks, only 
to cases where the energies of the uterus are great and 
manifest, but yet unequa,l to the task of overcoming the 
resistance rapidly, and where they evidently will over- 
comeit in a reasonable time. In other circumstances, 
as where the resistance is powerful and the pains poor 
and weak, let the just proportion be established, by means 
of the ergot, a glass of wine or the forceps, between the 
power, and the resistance it is destined to vanquish. 



When, at last, the head begins to emerge, it does so by 
pushing away the perineum before it, which continues to 
cover the cranium like a tight cap. It should be re- 
Ynembered that the direction of the forces is parallel to 
the axis of the superior strait ; but it is equally true that 
ihe direction of the movement is not in the same line, at 
this stage ; the head is repelled by the curved line of the 
sacrum : it is driven against the sacrum, but glides off 
from its curved plane towards the outlet ; from which, if 
unrestrained by the perineum, it would escape without 
much extension. It has happened that the head has 
passed directly through the perineum, perforating it as if 
a six pound ball had passed through it, without injuring 
the commissure of the vulva, or the sphincter muscle of 
the anus ; and there is supposed, always, to exist some 
danger of its tearing the anterior edge of the perineum, 
at least, when that point is unsupported. Hence the. 
general care of writers to direct that the perineum be 
supported. 

From the foregoing remarks, the student will be eca- 
bled to appreciate the value of this injunction concerning 
Q 



182 CONDUCT OF A LABOUR. 

support to the perineum, and to know how it ought to 
be executed. A towel should extend from the lower 
part of the sacrum up towards the top of the vulva, and 
be pressed against the parts in such a manner as to pro- 
tract or continue the inclined plane of the sacrum, 
whereby extension of the head will be enforced, and no 
danger occur of its being too strongly propelled against 
the now thin tissues, which might be lacerated were the 
head not to follow the curved line of its movements. 

The degree of pressure made by the hand must be 
proportioned to the exigences of the particular case. It 
should be always sufficiently great to cause the head to 
undergo extension, at least ; and, where the tissues yield 
with difficulty, so as to furnish grounds to fear their 
laceration, the further advance of the head may be 
safely counteracted, for a time, by pressure, whicli 
should be continued until the soft parts acquire dilatabi- 
lity. 

The young practitioner, and the student, should be 
warned against falling into a habit of beginning too early 
to support the perineum. If the part be too early pressed 
upon with a napkin, it might become heated, and thus 
lose its disposition to dilate : and it is assuredly not 
necessary to sustain it, or support it, until so great a 
degree of extension has taken place as puts it in some 
danger of being lacerated. 

The head is born : perhaps the cord is turned once, or 
even more than once round the child's neck, which it 
encircles so closely as to strangulate it. Let the loop be 
loosened, by pulling the yielding end of the cord, suffi- 
ciently to enable it to be cast off over the head. This 
cannot always be done : if so, in any case, let the child 
pass through it by slipping it down, along its body, over 
the shoulders. If it seem impossible to slip the cord over 
the head or shoulders either, it should be let alone ; and 
in a great majority of cases it will not prevent the birth 
from taking place, after the occurrence of which the 
cord can be cast off. Should the child seem to be de- 
tained by the tightness of the cord, as does rarely happen, 
or in danger from the compression of its jugular vessels, 
the funis may be cut with the scissors, and tied after the 



CONDUCT OF A LABOUR. 183 

delivery. Under such a necessity as this, a due respect 
for one's own reputation should induce him to explain, to 
the bystanders, the reasons which rendered so consider- 
able a departure from the ordinary practice indispensa- 
ble. I have known an accoucheur's capability called 
harshly in question upon this very point of practice. 

If the shoulders should not rotate, so as to bring one of 
them under the arch, that motion may be given by one or 
two fingers, introduced, and made to act upon the shoulder 
nearest the pubis, so as to draw it into its proper place. 
If difficulty occur, and the shoulder does not advance, 
press the child back against the edge of the perineum, 
and that will often afford room for the advance of the 
shoulder, which had been thrust over the top of the brim 
of the pelvis by the resiliency of the edge of the perine- 
um. I have sometimes caused the shoulders to descend 
immediately, by merely pressing the perineum down- 
wards and backwards — the child, whose shoulder was 
jammed up above the top of the symphysis pubis, slip- 
ping down behind the symphysis, as soon as the cause 
that pushed it forwards (viz. the pressure of the perine- 
um) was withdrawn. Sometimes the shoulder nearest 
the sacrum, and at others that nearest the pubis escapes 
first. The student will, in practice, readily perceive 
which one he ought to assist ; he will at times be com- 
pelled to try one, and then another, being uncertain 
which is likely to emerge first. 

It is considered bad practice to drag out the body, 
except in very particular circumstances : the womb 
and abdominal muscles are sufficiently powerful for that 
object ; and if it be permitted to come away slowly, we 
shall have a more complete contraction of the womb, 
and a more ready detachment and extrusion of the pla- 
centa. Therefore, it is better to leave the expulsion of 
the body to nature, merely removing any cause of delay, 
that may obviate its descent and escape. Where the 
delay is great, and the child becomes very black in the 
face, and the respiration is either not established or in an 
unpromising condition, we are fully warranted to expe- 
dite the delivery by making use of one or more fingers, 
fixed as a blunt crotchet in the axillae. 



184 CONDUCT OF A LABOUR. 

As soon as the child is born, lay it on its back, out of 
the reach of the waters, which sometimes stand in a 
deep puddle by the breech of the mother — the child 
ought never to be exposed to the danger of suffocation. 
If it breathes regularly, it is well ; if not, blow suddenly 
into its face, and drop some cold spirit upon the region 
of the diaphragm. These and a few smart frictions are, 
in general, all that are demanded. The cord should not 
be cut until the pulsations have ceased near its placental 
extremity : it would be vain to wait for its cessation 
uear the child's body, as doubtless blood is thrown into 
the arteries long even after the ligature is applied ; in 
fact, children do sometimes bleed at the cord hours after 
they have been dressed, if the cord have been imper- 
fectly secured. There is no need to tie the cord twice, 
unless there be twins ; which can always be ascertained 
by feeling for the uterine tumour. Tie only one liga- 
ture, and that at the distance of an inch or two from the 
belly, and cut the navel string, holding the cord tightly 
betwixt a finger and the thumb. If it be not held, it 
will spurt the blood sometimes to a good distance, and 
soil the bed, or even the practitioner's clothes. Conceal 
the cut end of the placental portion of the cord in the 
napkin with which the perineum has been defended, in 
order that its blood may not fly over the bed ; and then, 
give the child to the nurse. There is danger of drop- 
ping the infant if it be not properly taken hold of. It 
should be seized with the left hand, by one or both ancles ; 
the back of its neck ought to rest in the arch formed by 
the thumb and forefinger of the accoucheur's right hand, 
while its back lies in his palm, and the points of the re- 
maining three fingers are under its right axilla. If held 
in this manner, it can by no means fall to the ground. I 
have seen a child taken hold of under the arms by both 
hands, and lifted up in a manner I thought quite insecure, 
considering that it is slippery with the waters or blood 
from which it had just been taken up. 

Inmost cases the placenta comes away in eight or ten 
minutes — Dr Hunter thought in twenty minutes. The 
care required in regard to the placenta is considerable ; 
for no one can say, of any labour, that it will end well, 



CONDUCT OF A LABOUR. 185 

until the afterbirth is completely discharged. The 
French call the delivery of the placenta, emphatically, 
delivrance, delivery. We ought always to ascertain, 
after having given away the child, what is the state of 
the womb. Therefore place a band on the hypogastri- 
um, and if a hard tumour be felt there, the womb is 
contracted ; if the womb is either not to be felt at all, or 
is very soft and yielding, a few gentle frictions on the 
abdomen will cause it to contract ; and now if a finger 
be passed up to the os uteri, the afterbirth will be either 
felt in it, or just above it ; if in it, let the woman bear 
down immediately, while the cord is tightened by pull- 
ing moderately at it. The mass will descend slowly 
into the vagina, either edgewise or not ; if not edgewise, 
one edge may be hooked down with the finger, and a few 
efforts of bearing down will expel it from the vulva. It 
should be received in the left hand, and turned or twisted 
round several times, in order that the membranes may 
be gathered into a string or rope, so that, when they are 
drawn out, none of them need be left adhering to the 
uterine surface, where, by detaining portions of blood, 
they might give occasion to putrefaction, with offensive 
and injurious discharges. A complete, clean delivery 
ought always to be eflected, if possible. If the woman 
finds, the next day, that portions of membranes are hang- 
ing out of t!ie vulva, she becomes alarmed, or at least thinks 
her medical man careless or ignorant. Notwithstanding 
that the placenta may be carefully twisted, as above di- 
rected, we sometimes find that where the membranes have 
been very much broken by the child, or where they are 
extremely delicate, the cord we have formed by twisting 
them is breaking, so that a coiisiderable remnant of them 
is about to be left in the uterus, which we cannot get 
possession of without passing up the hand at least into 
the vagina. My custom, when I find the membranes 
breaking, is to cease pulling until I have wrapped them 
in a small rag, which enables me to twist them still 
more, and thus draw them entirely away. Now they 
are so slippery that they cannot be twisted with the fin- 
gers, but when a dry rag is wrapped round them we can 
Q* 



186 CONDUCT OF A LABOUR. 

twine them and pull them as much as we may think 
needful. 

It unhappily does not always befall that the placenta 
comes away soon: we may wait half an hour or an hour for 
the expulsion of the afterbirth, and yet upon examination, 
repeated from time to time, discover that it has not come 
within reach of the finger. Fricticms upon the abdomen 
are known powerfully to excite the peristaltic fibres of 
the alimentary canal ; but their effects upon the womb 
are far more decided : it may be said, that when made 
upon the hypogastrium, they generally compel the womb 
to recommence its contraction — some women are so ex- 
citable that a touch brings on the afterpains ; they ought, 
therefore, to be instituted. The consent of parts, also, 
causes the womb to act sometimes, as soon as the woman 
makes a strong bearing down eflfort, to which she should 
be urgently prompted, if needful. When a contraction 
has been procured by frictions, or in any other way, it 
may be rendered permanent by pressure ; therefore let 
an assistant be properly taught to apply the palm of the 
hand over the uterine globe, and not take it off until told 
to do so. In all those patients who habitually flood in 
labour, this caution ought to be obeyed. When the 
hand is removed, a bandage ought to be ready to occupy 
its place. If the os uteri be very much closed, it is 
probable that the placenta will require a long time to 
come away ; and I know no objection to a patient wait- 
ing for the spontaneous movement of the organ, where 
no hemorrhage or other unusual appearance is observed. 
Some writers have been disposed to assign a fixed period, 
up to which the accoucheur ought to wait, before he 
resorts to compulsory measures for the delivery. But 
there can be, or ought to be, no fixed rule on the subject, 
except this one rule, viz. the placenta must be got away, 
as there is no security while it is left. I have never 
gone away from a patient leaving the placenta undeli- 
vered. I think I have never waited for its spontaneous 
extrusion more than an hour and a half, for I have always 
supposed that if it would not take place in one hour, there 
was little prospect of its taking place in twenty-four hours. 
I cheerfully admit, however, that cases may and do 



CONDUCT OF A LABOUR. 187 

occur, in which a longer delay might be advisable. I 
have not met with such cases. I wish to be understood 
as speaking, in this place, of the placenta retained in 
utero, and not of cases where it is partly expelled into 
the vagina; for, when in the vagina, I think there can 
be no necessity of waiting at all ; it ought to be removed 
at once. Ruysch, the celebrated Dutch anatomist, zea- 
lously inculcated the doctrine, that, as the expulsion of 
the placenta is a natural office, it ought not to be inter- 
fered with, except upon the occurrence of symptoms 
making such intervention indispensable ; and his autho- 
rity having been deemed unquestionable, was yielded to 
by several physicians of eminence, who nevertheless 
found, after losing not a few patients from hemorrhage, 
inflammation, &c. the consequence of retained placenta 
— that experience is the best teacher ; and they therefore 
reverted to the custom of securing the expulsion of the 
secundines by artificial measures, wherever the powers 
of nature were incompetent to that function. 

A placenta will weigh from a pound to a pound and a 
half. Let the student reflect that such a mass, if within 
the uterine cavity, must distend it considerably; and if 
he cannot touch it by passing the finger up to the os 
tincse, the fundus of the womb must, of course, be high 
up within the abdomen. Therefore, in any case of re- 
tained placenta, he will find the fundus perhaps fully as 
high up as the navel. It will require, then, in order to 
get it, that the hand should be introduced : the finger 
cannot reach far enough. 

From the dilated state of the vulva and vagina, after 
delivery, no difficulty stands in the way of the introduc- 
tion of the hand into those parts. As it passes up it is 
guided by the forefinger, which glides along the cord, 
while that is tightened by the other hand. The reader 
must expect to find instances in which the os and cervix 
uteri actually gripe the cord ; and that he will be, in such 
a case, necessitated to introduce only one finger at first, 
then a second, and a third, which gradually conquer the 
resistance of the circular fibres of the os and cervix uteri, 
so as to make way for the whole hand, which at length 
is found to have entered into the cavity of the womb. 



y 



188 CONDUCT OF A LABOUR. 

But the pressure required in this operation has put the 
vagina, even the womb itself, on the stretch ; so that 
were he not to resist its rise by pressing the abdomen 
with the other hand, the fundus would be pushed up to 
the scrobiculus cordis, and his arm pass inwards as far 
as the elbow. In general, it appears to me that the ute- 
rus, in retained placenta, contracts by its circular or hori- 
zontal fibres, while its longitudinal contraction does not 
take place at all. It is, indeed, extremely common to 
feel the womb, like a large intestine, pretty firmly con- 
tracted as to its transverse diameter, while from the fun- 
dus to the OS uteri the length is not less than before the 
commencement of labour. Certainly it must have hap- 
pened to many practitioners to make this remark of the 
cases in which they were obliged to introduce the hand, 
for the extraction of the placenta. Let the operator, 
therefore, always stop the womb from rising, by coun- 
teracting it with one hand placed on the abdomen, over 
the top of the fundus, in order to push it downwards 
towards the hand which is within. Most probably the 
placenta is to be found partially detached ; if not, let the 
detachment be effected by getting one or two fingers 
under its edge or circumference, and thus peeling it off' 
from the womb, taking great care not to use sudden and 
indiscreet force, so as to hazard the leaving any of its 
lobuli in the cavity of the womb. Whenever all the 
adhesions are certainly overcome, the mass should be 
grasped in the hand, which may then be gradually with- 
drawn, holding the obnoxious placenta in its grasp ; or, 
if the womb is suffered to push the hand out, so much 
the better. This operation it has been my fortune to 
be compelled to perform a good many times ; and I can 
safely say I have never seen any bad results from the 
practice. It may be done so gently and dexterously, as 
even to occasion but little pain. 

The cord furnishes a most convenient means of pull- 
ing out the placenta, but should never be used for that 
purpose without a very careful reflection on all the cir- 
cumstances. If the afterbirth is still attached, and the 
uterus firm, to pull at the cord is to endanger the break- 
ing it off" even with the surface, which is an embarrass- 



CONDUCT OF A LABOUR. 189 

ing and rather disgraceful accident ; but if the womb be 
not firmly contracted, it is so flaccid, that, like a wet 
bladder, it may be turned inside out. I have seen a 
womb that was turned inside out by a midwife in this 
way, a case of great interest, that will form the subject 
of a future page. To any individual who has seen a 
womb at full term, nothing would seem to be easier than 
to invert a relaxed uterus. Wherefore, no man of dis- 
cretion ought to draw by the umbilical cord, without 
having first ascertained that the womb is well contracted ; 
and even then, the force he may venture to employ by its 
means is an exceedingly limited one. 

When the placenta is delivered, the hand should be 
soon placed on the patient's hypogastrium, for the pur- 
pose of ascertaining whether the uterine globe is firm. 
It ought to feel through the integuments about as large 
as the fist ; but there is great diversity in regard to the 
magnitude of the organ immediately subsequent to de- 
livery. The smaller it is the better for the patient, who, 
with a well contracted uterine globe, may be safely pro- 
nounced beyond the reach of danger from eflfusions of 
blood ; or at least, from effusions that can with propriety 
be denominated uterine hemorrhages. 

Inasmuch as the pains of labour alternate with inter- 
vals of rest or inaction, it follows that the pains which 
women suffer, whether before or after delivery, depend 
upon one and the same cause, viz. — the alternate action of 
the womb. The organ, after delivery, grows alternate- 
ly small and large for some hours ; expanding to double 
the size of the fist, when the pains are off, and reducing 
itself to the smallest size when they return. Every in^^ 
terval, or moment of expansion, permits a small quantity 
of blood to accumulate in the cavity, which is soon forced 
out by the returning pains. The woman feels the gush 
of warm fluid issuing from the vulva, and is very apt to 
say that she is flooding or flowing. An inspection of 
the countenance and an examination of the pulse are per- 
haps sufficient to indicate the course of the practitioner. 
If the face is not pale, and the pulse not weak or small, 
he will be sure she is not bleeding too freely ; but if 
they indicate the existence of too considerable a dis^ 



190 CONDUCT OF A LABOUR. 

charge, the amount of it ought to be ascertahied with the 
most rigorous precision. There are few nurses who are 
competent to decide upon the nature of the discharge ; 
as whether it amounts to what might be denominated 
hemorrhage or not I was called in haste to attend a 
woman whom I found just delivered of a child ; I re- 
ceived the afterbirth, which came off spontaneously, and 
observed that the sanguine discharge was very great, 
but the woman although feeble was not sunken. The 
uterus contracted well, and I left her in a comfortable 
and usual state. In about two hours I was summoned 
again, and found her very faint, with extremely feeble, 
slow pulse. Placing one hand upon the hypogastrium, 
I found the womb not dilated, and then inquired of the 
nurse as to the amount of the lochia. She assured me 
that it was not greater than it should be. She had ex- 
amined carefully into the circumstances and found all 
right. Distrusting her account, I determined to learn for 
myself whether a large effusion had taken place, and 
found an immense quantity of coagula lying upon the 
bed, which the nurse had either not seen at all, or disre- 
garded. This case, which afterwards caused me great 
trouble and anxiety, has influenced me ever since, and 
now I always feel unwilling to take information at 
second hand upon the important subject of profuse ute- 
rine discharges. I think it the duty of the student early 
to resolve to learn accurately whatever may have an in- 
jurious or dangerous tendency for the patient to be com- 
mitted to his charge. 

It may be stated as an axiom in obstetrics, which has 
almost no exception, that a well contracted uterus can- 
not bleed ; and all obstetricians habitually feel secure 
when they find the organ hard and of a small size. 
Nevertheless the state of contraction may soon be fol- 
lowed by so absolute a relaxation of the contractile forces 
of the uterus, that the gentlest infusion of blood into its 
cavity is capable of distending it again, if that fluid be 
prevented from escaping at the os tincae or at the vulva. 
But if a coagulum should fill the vagina, and stop the 
mouth of the womb ; or if the napkin should be too 
strictly pressed against the genital fissure, preventing 



CONDUCT OF A LABOUR. 191 

the escape of fluid therefrom, the blood which flows into 
the womb will gradually distend it to that degree, that, 
without losing a spoonful externally, the woman may 
efluse enough blood into the uterine cavity to expand it 
very greatly, and to cause fatal syncope. I was called 
about three years ago into the country, to assist a prac- 
titioner in a difficult labour. When I arrived, the child 
had just been delivered with forceps. The placenta 
was adherent. After waiting a suflicient length of time 
for its spontaneous extrusion, I removed it, and the 
womb contracted well. In the course of half an hour 
my attention was attracted by a sort of gurgling sound 
from the bed, which caused me to draw near to the 
woman, whom I found already quite fainted away when 
I approached her. She was very pale, and the pulse 
could not be felt at the wrist. The discharge was in- 
considerable ; but on placing the hand on the hypogas- 
trium, the womb was found enormously distended, and 
full of blood. Two fingers were now carried into the 
OS uteri, which was found to be tamponed with a very 
firm clot. This I broke up and brought away, when 
out rushed a large quantity of grumes, mixed with fluid 
blood, and the womb returned to its proper dimensions. 
She had no return of the symptoms. I could cite many 
examples from my case book, of violent hemorrhages, 
both concealed and open, which have fallen under my 
notice in females where the uterus had contracted per- 
fectly well after the delivery of the placenta. One case 
is so remarkable that I cannot resist the inclination to 
publish it here. 

Mrs S. was delivered of her first child after an easy 
labour. She had a very good getting up, and on the 
fifteenth day walked down stairs. Some words of an 
unpleasant character passed between her and her hus- 
band. She became violently excited with anger ; then 
burst into tears, and ran up stairs, where she threw her- 
self on the bed. She was shortly after found in an ap- 
parently dying state. When I reached the house there 
was no pulse ; great coldness, and the greatest degree 
of paleness. I found the womb filled with blood, and 
reaching above the umbilicus. Dr Dewees was so kind 
as to visit this patient with me, and assist me with his 



192 CONDL'CT OF A LABOrR. 

valuable counsel. She recovered, but suffered a long 
time under the symptoms produced by this excessive san- 
guine discharge. This case will show the student that 
even where the uterus has contracted so much as to sink 
down below the superior strait, it may be afterwards 
enormously distended by influent blood ; and the reflec- 
tion arising from it, though an unpleasant one, is a very 
just one, that even where we succeed in getting a good 
contraction, we can have no sense of absolute security 
against concealed or open hemorrhage, in a patient whom 
we may have put to bed ever so comfortable, and appa- 
rently safe. 

The influence of position in determining the momen- 
tum of blood in the vessels is well known to the profes- 
sion ; but there are few cases where it is of more conse- 
quence to pay a profound regard to this influence, than 
in parturient women. A uterus may be a good deal re- 
laxed or atonic, and yet not bleed, if the woman lie still, 
with the head low ; whereas, upon sitting up suddenly, 
such is the rush of blood down the column of the aorta, 
the hypogastrics, and the uterine and spermatic arteries, 
that the resistance aflbrded by a feeble contraction is 
instantly overthrown, and volumes of blood escape with 
an almost unrestrained impetuosity. The vessels of the 
brain under such circumstances become rapidly drained, 
and the patient falls back in a state of syncope, which 
now and then proves immediately fatal. 

In conversation with my late venerable friend Profes- 
sor James, upon this very subject, he informed me that, 
he delivered a lady a few years since, after an easy na- 
tural labour. The uterus contracted well, and all things 
seemed as favourable as possible. As the accouchement 
took place early in the morning, he was, subsequent to 
the event, invited to breakfast downstairs, whither he 
proceeded, after having given strict caution to the lady 
on the subject of getting up. While the persons at 
breakfast were conversing cheerfully, and exchanging 
felicitations upon the fortunate issue of affairs in the 
lying-in room, the nurse was heard screaming from the 
top of the stairs, " Doctor, Doctor, for God's sake come 
up !" He hastened to the apartment, and the lady was 
lying across the bed quite dead. It was found thai, 



CONDUCT OF A LABOUR. 193 

soon after the doctor went below, the lady said to the 
nurse, " I want to get up." " But you must not get up, 
madam, the doctor gave a very strict charge against it," 
replied the nurse. "I do not care what the doctor 
says," rejoined the patient; and thereupon arose, and 
throwing her feet out of the bed, she sat on its side a 
few moments, reeled, and fell back in a fatal fainting 
fit. The remarks of Dr James, as he related the occur- 
rence to me, have made upon my mind, a deep im- 
pression of the vast consequences of careful, and well 
timed instruction of the nurses ; who, if they could have 
the dangers of mismanagement fully exposed to them, 
would surely avoid some accidents that every now and 
then are attended with very shocking results. 

Large discharges are not apt to occur when the womb 
has once contracted pretty firmly. But there are pre- 
cautions which ought always to be observed : e, g. 

I left a woman half an hour after the birth of her child. 
She was as well as could be desired. I gave the usual 
directions. In a short time her husband came running 
to me, in the street, where he met me, and said his wife 
was dying. Upon hastening to his house I found her, 
in fact, pulseless, pale, and completely delirious ; with a 
constant muttering of incoherent phrases. Upon in- 
quiry, the following occurrences were found to have 
taken place. She felt some desire to pass the urine. 
The nurse told her to get up. "But the doctor says I 
must not get up." " Oh, never mind what the doctor 
says, it wont hurt you ; get up." A chamber-pot was 
placed in the bed, and Mrs F. was lifted up on it, in a 
sitting posture. She fainted in the woman's arms, was 
held up a short while, and, when laid down, the vessel 
was discovered to be half full of blood. She had nearly 
died ; and did suflfer long and severely in consequence 
of this impudent disregard of orders. When I left her, the 
uterus was well contracted ; but the change of momen- 
tum in the arterial columns produced the hemorrhage, 
than which, I have scarcely seen one more dangerous. 

It is of the highest consequence to secure a powerful 
contraction of the womb after delivery, in all those wo- 
men who have suffered severely from floodings, occur- 

R 



194 CONDUCT OF A LABOUR. 

ring soon after the birth of the child. A lady in three 
successive labours, of which the first occurred on the 
30th of December 1819, and the last on the 28th of Sep- 
tember 1824, which were rapid and easy, was brought 
almost to the gates of death by enormous discharges, 
which commenced about five minutes after the birth 
of the foetus. I saw her lie pulseless, and as near as 
possible to dissolution in those labours. In two subse- 
quent confinements, she took one scruple of ergot, just 
as the foetal head began to emerge. This was given 
to her, not for the purpose of aiding in the expulsion of 
the child, or placenta, which had never occasioned any 
embarrassment in antecedent labours ; but, by constrict- 
ing the womb permanently, to save her from those dan- 
gerous losses ; and I am pleased to say, that in both 
instances, she experienced none beyond the ordinary 
amount of effusion. I could cite numerous examples of 
similar results. 

I repeat the opinion already expressed, that the blood 
that issues from the placental surface of the womb ought 
to be permitted to flow freely out from the vagina. After 
it is effused it is of no use to the woman. What is the 
reason that a woman does not bleed to death after the 
placenta is detached ? It is not because a coagulum is 
formed, by which the effusion is arrested. She is saved 
by the condensation of the uterine tissue, which is not 
only sufficiently diminished, in volume, to close the small 
orifices of the vessels on the placental surface, but even, 
to close the largest sinuses that may be opened during 
the cesarian section, or in extensive lacerations of the 
womb. I repeat again, that a very firm clot, shutting 
the mouth of the womb, may serve as a tampon which 
shall wholly prevent the escape of blood from the cavity, 
which expands as it continues to receive the effusion, 
until the womb becomes fully as large as at the sixth 
month. Such clots should be broken up, and removed. 
They are as dangerous as, but not more so than, the 
artificial tampon, when used after delivery at term. I 
have never used a tampon after delivery at term ; but I 
have seen one used, which came very near causing the 
patient to sink, by detaining the effusion within the ca- 



CONDUCT OF A LABOUR. 195 

vity. The principle is false, and the practice dangerous, 
which resort to such a mode of arresting uterine hemor- 
rhage, at term. If it should be said, here, that women 
very commonly do discharge utero-morphous clots after 
delivery, I admit the fact ; but I subjoin, that but for a 
sufficient degree of irritability in such uteri, the clots 
would become so large as to require for their formation, 
a wasteful, and even dangerous or fatal extravasation of 
the vital fluid. Strong uteri never permit them ; weaker 
ones allow considerably large ones to be formed, and very 
feeble wombs fill until the woman faints or dies. 



I attended Mrs J. A. S., confined with her fifth child, 
in a labour that was perfectly natural, relatively to the 
birth of the child, the delivery of the placenta, and the 
symptoms that immediately ensued the parturient state. 

Having waited about half an hour, I took my leave of 
the patient about two o'clock in the morning, and had 
proceeded a good way towards my house, when I was 
overtaken by her husband, who entreated me to hasten 
back to the lady, as she seemed near dying. 

Upon returning to the house, I found my patient with- 
out pulse, the face of an excessive paleness, and the 
whole state expressive of the last degree of sinking or 
prostration. The idea that immediately became obvious 
was, that, she must have had a large efiusion of blood : 
but upon placing the hand on the uterine region, the organ 
was found well condensed ; while, upon careful exami- 
nation of the bed, no very considerable extravasation of 
blood was detected. I found that the abdominal parietes 
were very remarkably flaccid ; to such a degree as to 
strike me, forcibly, as aflfording incompetent support to 
the viscera within: indeed, the contractility of the abdo- 
minal muscles and integuments was so very slight, that it 
appeared to me the bowels could have derived almost no 
support from their pressure. 

After exhibiting such restoratives as were at hand, I 
folded two large towels into squares, and placing them 
upon the abdomen, as compresses, secured them by a 



196 CONDUCT OF A LABOUR. 

bandage, which retained them in situ, and thus afforded 
such a degree of support to the contained viscera, as I 
deemed sufficient to obviate the sinking and fainting ten- 
dencies, which always ensue from a loss of this support 
or pressure. I enjoined rest in a horizontal posture, 
removed the pillows from under the head ; and when 
the forces of the constitution rallied, there was no fur- 
ther alarm or distress. It has happened to me many 
times to meet with this syncopal state, after delivery, un- 
accompanied with hemorrhage, either internal or exter- 
nal ; and in all parturient persons, who are enormously 
distended, or who are prone to such faintings after de- 
livery, I take the precautions suggested by the above 
case in good time ; and can safely say, that, such precau- 
tions generally result in success. 

The effect of a removal of pressure or support from 
the contents of the abdomen, is noticed not only in 
labours, but in tapping the abdomen for dropsy. It is 
always deemed necessary, in very distended persons, to 
pass a broad roller round the abdomen, so as to constrict 
it in proportion as the water flows off. In cases of para- 
centesis, where this precaution is not observed, the pa- 
tient is very apt to faint, and evidently from the same 
cause I have mentioned, viz. the want of pressure on the 
contained organs. I had occasion, more than two years 
ago, to verify this principle in a case. A young woman, 
excessively distended with ascites, was tapped ; the water 
flowed off very rapidly : in proportion as it escaped I 
tightened the bandage, and she made no complaint of faint- 
ness. In order to test the effect of relaxing it, I withdrew 
all pressure for a very short time, the water still flowing, 
and she immediately began to grow sick and faint ; which 
symptoms ceased as soon as I renewed the pressure with 
the bandage. It is with the greatest confidence, both as to 
its necessity and efficacy, that I therefore recommend, that, 
a bandage should be early placed around the abdomen of 
such patients as are prone to fainting after delivery, as 
the compression, all things being ready prepared, may 
be applied soon after the birth, without disturbing the 
patient. 



CONDUCT OF A LABOUR. 197 



The diet of a woman recently delivered, ought to be 
very light, and of easy digestion ; tea, bread, gruels, 
vegetable jellies, and panada suffice, and are the safest 
materials during the three or four first days of the ac- 
couchement. Circumstances may demand a more liberal 
allowance ; but, for persons who have small lochial eva- 
cuations, or who are of an excitable constitution, the 
simplest elements of nutrition only should be prescribed. 
For a surgical patient, both before and after the comple- 
tion of the operation, a regimen is deemed of vital im- 
portance ; and yet the shock to the constitution, and the 
irritative influences of the wound, in severe or capital 
operations, are not greater than those developed by many 
instances of labour. In addition to these considerations, 
it ought to be remembered that during the months of 
gestation, the fluxional determinations have been towards 
the uterus ; but now the wave of vital fluids is marching 
towards another set of organs, and great disturbances are, 
many times, occasioned by this mutation of directions. 
The effort of the constitution produces fever, which com- 
mences simultaneously with the irritation of the mam- 
mary glands ; but, happily, when those glands are enabled 
to throw oflf an abundant secretion, the whole constitu- 
tion is relieved by the evacuation, and the fever suffers a 
crisis, as well marked as that of a bilious, remittent, or 
any other febrile disorder, that goes off" by a profuse 
diaphoresis or diarrhoea. Let the body, then, be pre- 
pared for this fever, by a correct course of diet ; and 
when that crisis has been completed, much of the hazard 
of an accouchement will be already overpassed, and a 
reasonable indulgence in stronger food become safe and 
proper. 



The child should be put to the breast as soon as the 
mother has recovered sufficiently from her fatigue and 
exhaustion. This is a natural course — it is, therefore, the 



198 CONDUCT OF A LABOUR* 

best one ; for by the act of sucking, the new deteiTnins- 
tions, about to arise, are invited to, and restrained within 
their proper bound : the vital wave ought to come hith- 
erto, but no further. Such a course is useful for the child, 
which generally procures, from the earliest lactation, some 
saline fluids, that have a favourable influence on its diges- 
tive tube ; and for which ought not to be substituted that 
pernicious compound, molasses and water, which every 
child in the country is doomed to swallow, at the expense 
of a sour stomach and flatulent bowels, displayed in the 
almost universally resulting symptoms of colic, green 
stools and vomiting. The antediluvian mothers had no 
molasses and water for their children, who lived, never- 
theless, a thousand years. Nothing can be more, cer- 
tainly, conformable to the dictates of nature, than an early 
application of the infant to the mother's breast. If we 
could suppose a woman in a state of nature, to be de- 
livered alone, under the shade of some native forest, and 
unsuspected, observe her conduct, we should witness the 
instinctive movements and promptings of nature, that 
would far better guide us in the management of such 
afl^airs, than the crude conceptions of those, who are 
ever ready to boast of the excellence of art or skill, 
over the calm suggestions of uninitiated nature. Such 
a mother would soon be aroused from the weakness 
and languor that succeed the pangs and throes of child- 
birth, by the cries of her helpless offspring. She 
would take it, as soon as a little returning strength 
should permit, into her arms, and the newly born child 
would probably not nestle a moment on the maternal 
bosom, without finding the source of its future aliment: 
the very anatomical structure, both of the maternal arms 
and breast, and the instinctive motions of the child's head, 
would bring its lips speedily in contact with the nipple. 
But we, wiser than our great instructress, often keep the 
new born child away from its natural resting place, and 
deprive it of the most appropriate nutriment, for two or 
three days, in order to eschew sore nipples, or to propi- 
tiate some other imaginary evil; while we allow the breast 
to fill almost to bursting, and actually to inflame from 
distension, before we admit that preparation to be com- 



CONDUCT OF A LABOUR. 199 

plete, which our presumptuous interference, in this man- 
ner, vitiates and troubles. The child ought to be put to 
the breast as soon as the mother is strong enough to take it. 



I need only refer the student to what I have already- 
said, concerning the injurious effects of sitting up after 
delivery, to bear me out in the opinion that a lady ought 
to keep her bed several days after the birth of her child. 
In general, on the third day, she may get up to have her 
bed made, and thenceforth may rise daily, provided all 
the circumstances of her situation are favourable. 



It is a good custom to give an aperient medicine on 
the third day, or about seventy hours after delivery ; 
while, in most cases, it is safest to defer the administra- 
tion, at least up to this period. The perturbations of vital 
action in the abdominal viscera, occasioned by medi- 
cines administered too early, are observed to result in 
symptoms of congestion, and of peritoneal fever, in not a 
few instances, particularly where an epidemic tendency 
to the latter malady exists. 

It should be well understood in the lying-in apartment, 
that no medicines are to be given to the mother, or the 
child, without the sanction or advice of the medical at- 
tendant. In our part of the country, it is exceedingly 
common for the nurse to take upon herself the function 
of prescriber, and to administer a dose of severe cathar- 
tic medicine, upon her own responsibility ; which, how- 
ever great and sufficient she may deem it, remains, after 
all, with the physician. He it is who bears the burthen, 
and undergoes all the trouble and anxiety, and responsi- 
bility of the management. He ought, therefore, always 
to direct that no interference with his rights should be 
suffered to take place. There are many reasons why 
he should be the sole director of the management ; for 
it is not a matter of indifference what particular article 



200 CONDUCT OF A LABOUR. 

is selected, any more thau it is of little consequence, at 
what moment the medicine (if any) be administered. 

Castor oil is the article in most request, for this period 
of the confinement ; and in a dose of half an ounce, ope- 
rates sufficiently well. Where the castor oil is particu- 
larly disagreeable, a proper quantity of magnesia and 
rhubarb ; of infusion of senna : of epsom salts ; of seid- 
litz powders, may be substituted ; but, in general, the 
oil is to be preferred, in consequence of the great cer- 
tainty and moderation with which it operates on the 
bowels. 

The lochial discharges grow gradually less abundant, 
and of a paler colour. The tone of the womb itself 
must determine, in a great measure, the duration and 
amount of the discharge. It disappears in the third 
week, and sometimes, earlier. Not a few women con- 
tinue to have a show in the fifth week ; and, in fact, the 
Jewish women had their purification at the fortieth 
day, which probably might be founded on observations, 
as well suited to the inhabitants of this country, as to those 
of the Holy Land. 



CHAPTER XII 



FACE PRESENTATIONS. 



In those cases wherein the usual dip of the occipito- 
frontal diameter fails to take place, but, on the contrary, 
is reversed, so as to allow the chin to depart far from 
the breast, the head is actually turned over backwards, 
and permits the child's face to fall down into the pelvis. 
These are what are denominated Face Presentations ; a 
sort of labours, that are thought less unnatural and dan- 
gerous, now, than in former times. I am clearly of opin- 
ion that face cases may well be included among the na- 
tural labours, except some failure in the powers of the 
woman should cause us to convert them into preternatu- 
ral ones, by obliging us to turn and deliver by the feet; 
to restore the vertex by some serious operation ; or to 
extract with the forceps. 

The foetal head is an oval, which is five inches long, 
from the vertex to the chin, and three and a half inches 
wide, at the widest part ; and it ought to make no differ- 
ence, as far as the mere head is concerned, whether the 
chin or the vertex advances first in labour, because, in 
either case, the same circumferences of the head are pre- 
sented to the parts through which they are to be transmit- 
ted. The foramen magnum of the occipital bone being 
nearly equi-distant from the vertex and chin, and situated 
on one side of the oval, the peculiar difficulties and hazards 
of these labours are attributable, rather, to the nature of the 
articulation by which the neck and head are conjoined, 



202 FACE PRESENTATIONS. 

than to the form of the head itself, when advancing with 
the face downwards. The nature of this articulation is 
such, that extension of the head cannot take place so 
well as flexion : hence the requisite dip of the occipito- 
frontal diameter is not effected without difficulty, and 
the consumption of much time. 

Let the reader figure to himself the state of the spinal 
column of a child, urged on, in labour, by powerful ute- 
rine contractions, directed to its expulsion with the face 
in advance. The inferior-posterior part of the head is 
pressed against the back of the neck, or betwixt the sca- 
pulae, which could not be the case, without bending the 
cervical spine backwards, like a bow, while the dorsal 
and lumbar vertebrae are curved in the opposite direction, 
causing thus a double antero-posterior curve, on which, 
in consequence of the elasticity of the two arches, much 
of the expulsive force is vainly expended ; so that, though 
the power may be great as common, it produces much 
less effect than common ; a great part of every pain 
being occupied in reproducing, at each time, the great- 
est amount of curvature (for the elasticity of the two 
curves is such, that they are straightened as soon as the 
pain subsides, at least in some measure) ; and the rest of 
the pain is used in pushing the face onwards. 

The direction taken by the face, as it proceeds, in such 
a labour, is worthy of the closest attention of the prac- 
titioner. If the chin enter the superior strait near to the 
acetabulum, it will afterwards rotate towards the arch of 
the pubis, and, escaping under that arch, will rise up- 
wards over the pudendum, so as to allow the throat to 
be applied to the arch, while the remainder of the head 
is evolving itself from the os externum. In such a 
birth, the part that first emerges is the chin; then the 
mouth, the nose, the forehead, the crown ; and, last of all, 
the vertex, Ayhich escapes over the fourchette, when the 
flexion of the head immediately becomes complete. See 
the Cut, 

This is the most favourable direction for the face to 
take, and it will generally be found that a well formed 
pelvis is capable of transmitting a child of moderate size, 
almost as speedily and safely, in such a labour, as if it 




203 



FACE PRESENTATIONS. 203 

were a vertex presentation. Let it be remembered that 
the symphysis of the pubis is only one inch and a half 
long, and of course, if the chin escape under the arch, 
the neck is so long that the throat dfn apply itself against 
the symphysis, allowing the-i-chin, nay the whole head 
to be born, before any part of the thorax of the infant 
begins to plunge into the excavation. 

A very contrary state of things from the foregoing 
obtains, where the chin, instead of revolving towards the 
front, turns towards the back part of the pelvis. Here 
the forehead must be born first ; then the nose ; the 
mouth ; the chin escapes from the edge of the perine- 
um, and then retreats towards the point of the coccyx, 
allowing the crown of the head to pass out under the 
arch ; and lastly, the vertex emerges, which concludes 
the delivery of the head. But, while the chin is sweep- 
ing, slowly and painfully, down the curve of the sacrum, 
and especially when it is got so low as the edge of the 
perineum, the breast of the cliild is entering the pelvis, 
where the space it should occupy is already taken up by 
the perpendicular diameter of the head. Imagine the 
enormous extension of the os externum, required for the 
exit of the child, in such a case ! 

The Cut shows the difficulty, that is produced by a 
rotation of the chin backwards, in so clear a light ; that 1 
hope it may greatly assist in teaching the young student 
how extremely important a matter it is, to give all pos- 
sible aid and assistance to nature, in her attempts to 
turn it towards the front of the pelvis. 

The cause of face presentations is not perfectly well 
understood; it is, however, probable, that they are more 
commonly occasioned by an obliquity of the womb, than 
by any other cause. Let the womb, at the onset of la- 
bour, be so oblique as to throw its fundus far down to the 
left side, the child presenting by the head, and the vertex 
to the right side of the pelvis : the direction of the ex- 
pulsive force operating on the infant, will propel its head 
against the edge or brim of the pelvis, and either cause 
the head to glance upwards into the iliac fossa, so as to 
let the shoulder fall into the opening, or it will be turned 
over, so as to let the face fall into the opening, and thus 



204 FACE PRESENTATIONS. 

produce a face presentation, in which the chin is to the 
left acetabulum, and the forehead to the right sacro-iliac 
junction. It is easy t®* set\this in a clear Fight, espe- 
cially if it be accomJTaiiled with demonstrations on the 
phantome. *1y * 

In my opinion, it would o&Tight to admit, in a system- 
atic arrangement, only two origina^ positions of face pre- 
sentations ; viz., one with the cmn to the left, and one 
with it to the right of the pelvis ; it being always under- 
stood, that the position is not necessarily exactly trans- 
verse, but that the chin may be variously situated, 
sometimes being so far back as to be near the sacro-iliac 
symphysis, and sometimes more anteriorly, or near the 
body of the pubis. By admitting these two positions 
only, the student's mind is relieved from the burthen of 
unnecessary artificial distinctions ; and should he in 
practice rest upon them, it will be easier for him to com- 
prehend the practical doctrines relative to the case. 
Thus, in all face cases, the great doctrine is to bring 
the chin to the pubic arch ; and there are two positions, 
in which the chin naturally tends to the arch, if the po- 
sition be just and good ; or it may tend to fall into the 
sacral curve, if it be not just and good. Suppose we 
were to make four positions : 1, Chin to right sacro- 
iliac symphysis; 2, Chin to left sacro-iliac symphysis ; 
3, Chin to left acetabulum ; 4, Chin to right acetabu- 
lum ! What good result would we obtain, since, in all 
these cases, there will be found very great differences ? 
for, in the first, the chin may be more or less near to the 
sacro-iliac symphysis at one time than another, in some 
instances being nearly transverse, and in others not quite 
so far backwards. If we adopt all four positions, wo 
must have a doctrine for each ; but with the two only, 
there is a necessity for only one doctrine — viz., bring 
the chin to the arch of the pubis, if practicable. 

Face presentations are accidents ; and, perhaps, they 
are so unlikely to happen, that, they ought to be regarded 
as examples of preternatural labour. Yet, when we 
come to reflect, that the female caruexpel the child witli 
but little more difficulty, in this case, than in vertex posi- 
tions, it seems altogether proper to regard them as natural 



FACE PRESENTATIONS. 205 

cases. But I have said that they are accidents, and I 
helieve that they are chiefly caused by deviations of the 
axis of the womb. If a female have a very great right 
lateral obliquity of the womb, and the vertex present 
towards the left side of the pelvis, it may be impelled 
against the brim in such a manner as to glance above it, 
and allow the forehead to fall into the opening, which 
state could not exist long without being followed by the 
descent of the face. It should be observed here, that, 
from the chin to the vertex is a distance of five inches, 
which none of the diameters of the strait will take in, 
in the living subject : therefore, if the vertex should rise 
above the brim, and let the forehead fall into the opening, 
the chin would gradually come down. Let not the student 
then expect to find the face looking full down into the 
excavation, at the beginning of these cases, but rather, 
let him expect to find it coming more and more com- 
pletely dovvn as the labour draws to its close. 

Suppose a case of face presentation to be caused by a 
right lateral obliquity of the womb, the head being repelled 
above the edge of the strait : the womb, in its oblique state, 
leans to the right 2ind fo near ds, and not directly towards 
the right ; whence, if the accident occur in the manner 
supposed, the chin could not fail to be placed to the right, 
and a little forwards ; the same thing is true of cases 
caused by left lateral obliquity — mutatis mutandis — as 
before stated. This furnishes a striking manifestation of 
the wisdom which, in giving form to the pelvis, even pro- 
vided us herein a remedy for the accidents that might 
occur to thwart or prevent the parturient act. Should the 
chin be towards the posterior part of the pelvis, and not 
susceptible of being directed towards the front of the body, 
the most serious mischiefs might be expected to occur ; 
whereas, when the chin advances towards the pubis, 
little embarrassment is, in general, to be apprehended. 

If we could know, antecedently to the descent of the 
presenting parts, what they are, it might be supposed 
that we could easily restore them to their proper situation, 
when wrongly placed; but, while the presenting part of 
the child is above the brim, it is very rare to have such 
a good degree of dilatation as to admit of the hand being 



206 FACE PRESENTATIONS. 

introduced, in order to effect the needful changes. The 
womb opens as the part comes down. Hence, when a 
face case is ascertained to exist, it is mostly (I say not 
universally) too late to return it into the abdomen or 
superior basin ; and as for bringing down the vertex, after 
the head has once sunk well into the excavation, I re- 
gard it as a rash, if not an impossible act ; rash, since 
it could not be done without very great violence ; and 
generally, impossible, since we cannot turn, or seesaw 
a diameter of full five inches, in a pelvis furnishing less 
than that space. Where it is possible to push the whole 
mass back, and bring down the vertex, let it be done. 

Dead, and half putrid children, in whose tissues there 
is scarcely any resiliency or resisting power left, are not 
so unapt to come face foremost as living children, in 
whom departure of the chin from the breast occasions 
such a great extension of the head as to be painful, whence 
the child opposes the wrong tendency, by acting with all 
its strength, to get the chin down, or the head flexed 
again. 

Let me repeat that it is not to be expected, that, at the 
very beginning of a labour, the face of the child shall be 
found looking directly downwards. It is the forehead 
that is first felt ; and the face itself does not appear in the 
excavation for some time after the commencement of the 
parturient throes. The head turns over only by degrees, 
and allows first one eye to be felt and then the other, the 
nose, the mouth, and the chin. In order to exemplify 
these processes, I shall cite some cases from my record- 
book. 

On the 5th day of February 1830, 1 was called to at- 
tend Mrs , in labour with her second child. 

When I reached her house, it was half past six o'clock 
in the morning. She told me that she had had pain for 
a day or two, but was seized with regular labour pains 
at four o'clock this morning. Upon making examination 
per vaginam, I found the os uteri from one inch and a 
half to two inches in diameter, with the edges thin and 
very ductile, and the membranes were protruding through 
them very tensely during the pains. I could, at first, 
just feel the even smooth surface of the foetal cranium, 



FACE PRESEXTATIONS. 207 

which seemed to be resting or lodged upon the top of 
the symphysis pubis, and not in the least degree en- 
gaged, or entered into the superior strait. 

As the pains were regular and good, I expected soon 
to find the head engaged within the passage, but I observed 
that the uterus was very large, as if distended with an 
undue amount, or excess of liquor amnii. 

At nine o'clock A. M., the pains, although regular and 
of increasing severity, had not caused the head to engage 
in the slightest degree : it remained exactly as at the first 
Touching. These circumstances led me to suspect that 
the womb was unprovided with a proper degree of ener- 
gy, on account of its being distended beyond its just 
dimensions. I, on this hypothesis, deemed it advisable 
to rupture the ovum, in the expectation that, as soon as the 
womb should condense itself a little by the flowing oflT of 
the waters, it would acquire such vigour as to compel 
the head to engage in the strait, and thence pass speedily 
into the excavation, as I had repeatedly observed to be 
the case in other persons. 

Upon rupturing the ovum, there came off a very great 
quantity of water ; I should think nearly two quarts in 
all ; but the head did not advance until three or four pains 
had acted upon it ; after which it came slowly down, and 
I felt a suture ; but as yet no fontanel was distinguish- 
able. The examination induced me to suppose it was 
a vertex presentation of the first position, in which opin- 
ion I was most egregiously deceived by the very care- 
less manner in which I made the investigation. At 
eleven o'clock I made a more careful inquiry, and was 
distressed to find that the left side of the os frontis was in 
the middle of the excavation, and that, by passing the fin- 
ger very strongly up towards the left sacro-iliac junction, 
I could feel the left orbit and the nose, beyond which it 
was impossible for me to reach, in the then state of the 
organs of generation. 

It seemed, on account of the advanced state of the la- 
bour, too late to turn, if that even could have been consi- 
dered the best recourse ; and I was the more averse from 
such a proceeding, considering that I had, before, deli- 



208 FACE PPvESEXTATIONS. 

vered her of a large child, and also, that the waters were 
now drained off, and the uterine contractions powerful. 

As she had by this time become heated, and very 
much disquieted with her pains, from which the suffer- 
ing was severe, I gave her thirty drops of laudanum ; 
and soon afterwards, took twelve ounces of blood from 
the arm. She also got an enema, of flaxseed tea and 
olive oil. 

The head was now fairly engaged, and the face was 
becoming more and more the presenting part, notwith- 
standing my repeated endeavours to push it up, by for- 
cibly pressing against the ossa malarum, during each 
pain ; and I became thoroughly convinced that it was 
impossible to force up the face and bring down the ver- 
tex, by the employment of any legitimate force, or by 
mere dexterity. 

The pains had become so dreadfully severe, and the 
poor lady suffered such agonies, that I really entertained 
serious apprehensions that the womb might rupture it- 
self or the vagina, in its vain efforts to carry on the par- 
turient processes, lashed as it was into a rage of excite- 
ment by the obstacles to delivery. 

At my request, Dr James, the Professor of Midwifery 
ip the University of Pennsylvania, was invited to see the 
patient, and arrived at two o'clock in the afternoon ; and 
after having examined the case, left me, with encourage- 
ment to hope, that the vertex might come down, after 
some further efforts of the womb. Dr J. was to return 
to me at half past four o'clock. 

In the mean time, I provided myself with the long 
right-hand blade of Davis's oblique forceps ; and when 
the professor returned, at four o'clock, it was found to 
be vain any longer to expect the descent of the vertex. 
I therefore introduced the blade, above mentioned, behind 
the right ramus of the pubis — got it upon the right pari- 
etal bone — and, using it as a vectis, drew down with it 
during the pains. The head advanced very much by 
this aid, and began to press upon the perineum ; but 
there it stopped, and seemed no longer affected by the 
vectis. 

I next attempted, with my French forceps, to introduce 



FACE PRESENTATIONS. 209 

the male blade behind the left obturator foramen. I was 
foiled, but Dr James succeeded in adjusting it. Every 
attempt to adjust the female blade, whether made by Dr 
James or by me, proved fruitless. They could not be 
made to lock; nevertheless, I attempted to deliver with 
them by securing the joint with one hand, and by this 
means the head again advanced, but soon stopped. The 
forceps were now abandoned, after vainly attempting to 
make them lock. I now resorted to the oblique vectis 
again, and with it caused the head to advance so much as 
to put tiie perineum in a state of tension. The face 
turned to the pubic arch ; the chin emerged from the 
genital fissure; and as the successive portions of the 
face came forth, the chin rose up to the mons veneris, 
and allowed the fourchette to slip backwards off the ver- 
tex, which immediately retired towards the coccyx. 

The child was born, but the cord, which was round 
the child's neck, did not pulsate ; the infant, however, 
began to gasp, and, after having been well dashed with 
brandy, cried lustily. It was born at half past six o'clock 
P. M., so that the labour was found to have continued 
about fourteen or fifteen hours. 

At the time I last put on the vectis, the child's face 
was in the left sacro-iliac corner of the pelvis. Both 
Dr James and I expected that the rotation would inevi- 
tably carry it to the sacrum, and the chin be consequently 
delivered at the perineum. 1 have every reason, there- 
fore, to believe that the vectis was the chief means of 
giving the head so favourable a rotation, a result attribu- 
table to the admirable curve of Dr Davis's oblique blade. 

The perineum was not hurt; the placenta came off in 
twenty minutes ; and the mother found herself very 
comfortable, considering her great fatigue. 

The face was one enormous suggillation, carried to 
the extent of producing numerous blebs, or vesications 
on the eyelids and cheeks. The mouth was extremely 
swelled, and the left eye completely closed. The face 
was, on account of this state, directed to be frequently 
bathed with cream. This infant was carefully weighed 
on the evening of its birth, and was found to weigh nine 
pounds and three quarters. On the sixteenth day after 
s* 



210 FACE PRESENTATIONS. 

delivery the lady was down stairs to dinner, and had no 
subsequent indisposition. 

In giving the details of this case, I am liable, as I well 
know, to the charge of having, in an important matter, an- 
ticipated my subject. But although I have not yet come 
to the formal consideration of forceps cases, I feel pretty 
well assured no evil will happen to any student for having, 
by reading the foregoing relation, in some degree antici- 
pated the regular and formal consideration of forceps 
operations. 

The Cut, which represents the foetal head, in a face 
labour, thrown back to that degree as to press the occi- 
put against the interscapular space, suffices to show how 
well founded were my fears lest the forehead, instead of 
the chin, should rotate to the front, to prevent which is 
the chief doctrine of this obstetric topic ; and I would 
again urge the student to take the first opportunity that 
may present itself, of testing the doctrine, by trying to 
deliver on the machine, or phantome, with the chin back- 
wards, in a face presentation. By so doing, he will, at 
once, have a demonstration of the point of practice to be 
adopted, and never afterwards be in the least danger of 
making a mistake, or committing a blunder in this mat- 
ter. 

A case of a different kind occurred to me on Wednes- 
day, the 17th of February 1830. Mrs M. was in labour 
with her seventh child, having been taken at four o'clock 
A. M. with the pains, which continued to increase up to 
the time when I arrived, which was about half past six 
o'clock. The pains were strong; the waters gone off; 
and the head pretty low down in the pelvis. At my first 
examination, I mistook the position, thinking that it was 
a vertex case ; but as the pains seemed to have no good 
effect, I examined again, and could feel the root of the 
nose directly behind the symphysis pubis, and the su- 
perciliary edge of the orbit upon each side of the sym- 
physis of the bone. 

Upon this discovery, I endeavoured to turn the fore- 
head towards the left, by raising the os frontis and push- 
ing it in the proper direction ; but as soon as each pain 
came on, it forced the presenting part back again into its 




210 



FACE PRESENTATIONS. 211 

former position. I next endeavoured, by simply push- 
ing up the forehead during the absence of a pain and 
sustaining it while the pain was active, to cause the 
vertex to descend along the curve of the sacrum and the 
perineum : but I could not succeed here any better than 
in my attempts at rotation ; the pains drove it back, 
maugre all my wishes to the contrary. 

The patient, who had met with no such difficulties in 
her former labours, and to whom I was a stranger, now 
became greatly alarmed and distressed, so much so, in- 
deed, that 1 judged it most prudent to explain to her the 
true situation of affairs, and encouraged her to look for 
relief after a reasonable time. I told her that she could 
be delivered by her own unassisted efforts ; but that it 
would take a good deal of time, and much pain : but 
that I could speedily deliver her with the help of an in- 
strument, which would add neither to the hazard or pain 
of her condition. She clapped her hands ; trembled 
violently, and uttered exclamations indicative of the 
greatest dismay, and even terror, but at last agreed to be 
guided by my opinion. 

I introduced the right-hand long blade of Davis's ob- 
lique forceps, with which I caused the head to make a 
considerable advance ; but it again stopped, and I ap- 
plied the long forceps : with the aid derived from this 
instrument, I drew the head downwards so as greatly to 
extend the perineum ; upon observing which, I deemed it 
prudent to remove the forceps, lest I might rupture the 
perineum, which was about to undergo, unavoidably, a 
very great distension, and which I was not inclined to 
augment unnecessarily. After removing the forceps, 
I re-applied the vectis, as before, and it very greatly 
assisted me to bring the head onwards as far as was re- 
quisite. As soon as I withdrew the vectis, a pain came 
on, by which the head was expelled, the vertex passing 
out over the fourchette, upon which it immediately com- 
pleted its act of extension, and allowed the crown, fore- 
head, nose, and chin, successively to escape under the 
pubic arch. The child was born alive, and the afterbirth 
followed in ten minutes. Upon the infant's forehead was 
an enormous black suggillation, which disappeared in the 



212 FACE PRESENTATIONS. 

course of a few days, and was followed by no inconve- 
nience. 

Of the above case, it is proper to remark, that, the mo- 
ther was very well formed, and the pelvis large ; the 
child of medium size ; and although it did not become 
actually a face presentation, but was, the rather, a case of 
presentation of the forehead, it still serves to illustrate 
my observations on the difficulty of converting face pre- 
sentations into those of the vertex. I think that but for 
the aid of the instruments, it must have at last brought 
the face from behind the top of the symphysis pubis to 
look fully down into the excavation ; for the difficulty of 
restoring the vertex, although not insuperable, was ex- 
ceedingly great. In the course of my practice, I have 
met with a considerable number of cases like the one 
whose relation I have just given, but it seems unne- 
cessary to cite them here, as I presume this one may 
suffice to explain the nature of the mechanism of such 
a labour. 

I find, in my case book, another example of face pre- 
sentation, which I shall not deny myself the privilege of 
laying before my reader in this place, because it offers 
good encouragement to those who may happen to meet 
with such untoward sorts of labour in the commencement 
of their practice. 

October 11th 1830. Mrs C. W., aged twenty-six, in 
labour with her first child. I was called at twelve o'clock 
last night. She had been poorly throughout the day, 
but kept about until bedtime. At ten P. JVL, had a vio- 
lent pain and large discharge of waters. She lay on 
her left side. Upon touching, I could not reach the os 
uteri, nor feel any part of the child. Upon causing her 
to turn on the back, I was enabled, by pushing the finger 
very far upwards and backwards, to hook the anterior lip 
of the OS uteri, and draw it, by means of the finger, down- 
wards and forwards, into the centre of the plane of the 
upper strait : I then could touch the child's cranium, but 
could not touch a sufficient portion of it to learn what 
part of the cranium it was. Not long afterwards, I felt, in 
the left anterior part of the upper strait, a ridge or edge, 
which I soon made out to be the superciliary edge of the 



FACE PRESENTATIONS. 213 

orbit of the left eye, the globe of which soon came into 
my reach. I could not touch the anterior fontanel. 

Here then was a case which was to be a face presen- 
tation at last, if 1 should prove unable to prevent it by fail- 
ing to restore to the head its lost flexion. I vainly tried 
to do this by pushing up the forehead, and holding it up 
during a pain. It always came back to its place in spite 
of whatever efl'orts I could make. I next introduced the 
whole hand except the thumb, took hold of the vertex by 
a fair purchase, but could not turn it downwards, and at 
length becoming convinced of the impossibility of suc- 
ceeding, I resolved to abandon such irritating efforts. 

As the head sunk lower and lower, there was an obvi- 
ous tendency of the face towards the left sacro-iliac junc- 
tion. I opposed this movement of the head by pressing 
the finger on the right side of the nose, which kept it from 
turning to the left, and at last brought it to the obturator 
foramen. The face came more and more down into the 
excavation, and began to swell very much. The lips 
became excessively tumid and excited, and the whole 
face at last felt like a tense bladder. By the force of 
the pains, alone, the chin was afterwards slowly .brought 
to the OS externum, and applied itself to the top of the 
pubic arch, under which little by little it emerged, and 
then rose up towards the mons, permitting the front of 
the throat to take its place under the arch, and thus al- 
lowing the vertex to escape last from before the four- 
chette. 

The placenta came off in six minutes. The infant 
was very weak, and its face greatly swollen, and black 
with the suggillation. It soon cried loudly, and I find 
that on the 14th, i. e. three days after its birth, it was 
in fine health, and without any swelling of the face. 
The mother had a very favourable getting up. The 
net weight of the infant was nine and a half pounds. 
The mother was a large and very powerful woman. 

Madame Boivin informs us in her Memoires sur I'Art 
des Accouchemens, page 276, that out of seventy-four 
cases of face presentations, fifty-eight children were born 
naturally. Of these, forty-one were delivered without 
any assistance, and seventeen, by restoring the vertex to 



214 FACE PRESExNTATIONS. 

the centre of the excavation. Fourteen cases required 
the turning and delivery by the feet, while only two 
were extracted by the forceps, and in one of the latter 
cases, the mother had convulsions. 

" Thus," says the learned lady, " although present- 
ing by the face, the child may be born alive and natu- 
rally, provided the head be not too large ; if the parts 
of the mother are well formed; the pains strong and 
good ; the woman resolute and healthy ; and no acci- 
dent occur during the course of the labour." 

Madame Lachapelle, whose vast experience, gained 
while at the head of the Maternite Hospital at Paris, 
gave her undoubted claims to speak as from authority, 
and whose thorough knowledge of the theory of mid- 
wifery must confirm those claims as rights, gives us 
only two sorts of face presentations : one in which 
the forehead is to the left, and the chin to the right of 
the pelvis, and the other in which the forehead is to 
the right and the chin to the left. She says she never 
met with Baudelocque's first and second positions ; and 
Dr Dewees, who asserts that his list comprises near 
nine thousand labours, also informs us that he never 
met with them. It will be remembered by the reader 
that the second case which I related in this chapter, 
that of Mrs M., was one in which I felt the root of the 
nose behind and above the symphysis, and the two 
orbits on each side of it; and they will admit that 
although the vertex was at last restored so as to escape 
first, yet this was a real example of a face case of the 
rarest occurrence. Smellie gives us at least four exam- 
ples of the face presenting in Baudelocque's first or 
second positions ; and assuredly no English or Ameri- 
can student of midwifery will be disposed to call in 
question the accuracy or candour of that admirable au- 
thor, notwithstanding that Madame Lachapelle tells us 
she finds no very evident examples of such face positions 
in any good collection of cases. 

For my own part, I do not perceive the great im- 
portance of dwelling with much emphasis upon all the 
possible positions of the face. It cannot be doubted that 
they are each possible. The more important and use- 



FACE PRESENTATIONS. 215 

ful knowledge is that which teaches us the nature of 
the accident, and the appropriate indications of treat- 
ment. But we have already seen that the accident 
consists in an excessive departure of the chin from the 
breast, or failure of flexion ; that is the first principle : 
and the principal indication founded upon it, is, to restore 
the flexion by pushing up the forehead and bringing 
down the vertex ; and where that cannot be done, the 
next indication is to rotate the chin to the front, so that 
flexion may take place as soon as possible after the chin 
has emerged. 

As I shall have occasion to revert to the consideration 
of face positions when I come to treat of the various 
uses of the forceps, I shall close the present chapter, in 
order to open a new one, on the positions of the head. 



CHAPTER XIII, 



ON THE POSITIONS OF THE HEAD, AND 
THEIR MECHANISM, IN LABOUR. 



If there be a true republic of letters, t?ien there ought 
to be an equality of rights and privileges for each indi- 
vidual composing that republic. There ought to be no 
tyranny ; no exactions upon faith or practice, except by 
laws regularly enacted by the representatives of all the 
persons concerned in their operation. But it happens 
in the republic of letters, as in every civil polity, that 
there be demagogues, who set their faces, as a flint, to 
lead or seduce the people, into such ways, and such only, 
as may be laid out for them ; or else, seizing upon su- 
preme authorrty by a real usurpation, they endeavour to 
extort an obedience and conformity, by force of their 
mere supremacy, and not by addressing the sober and 
calm convictions of the people. The disciples of Py- 
thagoras were accustomed to reason altogether by the 
law of their master's will ; and it was sufficient evidence 
for them, when they could say ipse dixit, or magister 
sensit : and so great was the power of Galen over men's 
minds, that he ruled in medicine as with an iron crown, 
for fifteen centuries ; and so completely had he control 
over his asseclae, that one of them, Avicenna, declared, 
Se malle cum Galeno errare, qiiam cum omnibus aliis 
bene sentire. 

It cannot be denied that great men ought to, and do 
exert a powerful sway over the opinions of their ad- 



ON THE POSITIONS OF THE HEAD, ETC. 217 

mirers and followers ; but they should always be held as a 
sort of suspected persons, and their decisions and dogmas 
received with that degree of respect to which their au- 
thors are entitled, and not as laws never to be abrogated or 
called in question : for it is aright, common to the hum- 
blest as well as the most elevated member of the profes- 
sion, to seek for the elements of his opinions or judg- 
ments, not in written opinions, or in the dicta of those 
who are supposed to be masters in our art, but rather 
in patient investigation of the facts which come under 
his own observation. Those who are subservient to 
authorities never reason so well, or act so well as those 
who make up an independent judgment based on severe 
study, not of words but of things, not of theories but of 
nature herself. 

The ancients seem to have made very little progress in 
the cultivation of midwifery ns a science; and although 
there were skilful surgeon-accoucheurs in Europe more 
than two hundred years ago, such as Mauriceau, for 
example, still, the true nature of the processes by which 
children are ushered into the world, at the full term 
of pregnancy, was imperfectly understood. Great im- 
provements have been made in very modern limes : and 
it is not quite one hundred years since we first began to 
learn that the head generally enters the pelvis in an 
oblique direction, and leaves it in an anlero-posterior 
one; the first clear account of the matter having been 
given by Sir Fielding Ould, of Dublin, about the period 
above mentioned. Certainly, that great man, Mauriceau, 
who was in his greatest activity and fame at the begin- 
ning of the seventeenth century, never gave any account 
of the rotations of the head, or the real mechanism of 
labour, although it is not to be supposed that he could 
be ignorant of a fact of such common occurrence, in his 
great practice; but a majority of mankind are capable 
of knowing and appreciating a truth, without, perhaps, 
the smallest disposition to make a great noise about it. 
Mauriceau, for instance, must often Jjave felt the os 
occipitis directed towards the acetabulum, and found it 
to rotate towards the arch, as a regular occurrence in 
labour ; yet he did not say so. The knowledge of this 



218 ON THE POSITIONS OF THE HEAD, 

rotation is, however, of the greatest consequence ; and, 
for the purpose of rendering the proper assistance to 
persons in labour, the medical attendant should always 
be capable of ascertaining the diagnosis of the position 
for the time being. Of this he can learn nothing without 
touching the head of the infant before its birth, which 
operation of touching the child is called the examination 
per vaginam. 

If the patient's assent can be obtained, after the proper 
reasons for asking the privilege of making an examina- 
tion have been laid before her, we should have two 
principal objects in view, while performing that opera- 
tion : one of these is, to note the presentation, and 
the other, the position. There are other observations to 
be made at the same opportunity, such as the degree of 
softness or relaxation of the parts — their moisture or 
dryness— the state of the rectum — the sensibility, &c., 
&c. 

Upon obtaining the patient's consent to ihe examina- 
tion, she should be requested to lie on the bed upon her 
left side, with her hips near the foot of the bed, and the 
knees drawn upwards towards the abdomen, a small 
pillow having been previously placed betwixt the knees. 
Except upon occasions of the greatest emergency, a 
third person should always be present, and the physician 
ought to refuse to perform the operation of touching, 
except in the presence of a third person, who ought 
to be some elderly individual, acting as the nurse for the 
occasion. 

Let the attendant provide a napkin, and a small quan- 
tity of pomatum, lard, or other unctuous substance, and 
a basin of water for the hands. When a smart pain 
comes on, the left hand of the practitioner being pressed 
against the sacrum of the patient, outside of the bed- 
clothes, the forefinger of the right hand, properly 
anointed with the lard, should be introduced into the 
vagina, taking care not to bruise or irritate the patient 
by any rougli or hasty proceedings. If the point of the 
finger be now carried towards the upper extremity of 
the vagina, the os uteri is felt, and its degree of dila- 
tation ascertained. When the finger comes to the os 



AND THEIR MECHANISM, IN LABOUR. 219 

Uteri, if the pain still continues, let the greatest care be 
taken not to rupture the chorion, or the bag of waters, 
as it is called, especially in a first labour. These mem- 
branes are extremely tense during the pain, which forces 
them down through the opening of the womb, forming 
the segment of a sphere, of greater or less size, accord- 
ing to the greater or less degree of the dilatation : if 
they should be too roughly touched while in a state 
of tension, they might burst, and permit the liquor 
amnii to escape ; an unfavourable event in the early stage 
of labour, which it both retards and renders more painful. 
There is no need for pressing against the bag of wa- 
ters during the pain, because, by waiting until the pain 
subsides, the bag becomes relaxed, and can then be 
pushed back again within the mouth of the womb, so as 
to enable the finger to touch the head. For the most 
part, we only ascertain, in such an examination, the 
presentation, and being satisfied with that, we wait un- 
til a great dilatation, or the discharge of the waters, al- 
lows us to discover the position. During the operation 
of touching, we endeavour to learn the condition of the 
orifice of the womb, as to whether it is rigid, unyield- 
ing, or soft and dilatable ; whether it be thick and dry, 
or thin and moist with an abundant discharge of glairy 
phlegm. We also ascertain if the os uteri is in a favour- 
able position, i. e., in the middle of the pelvis, where 
it ought to be ; or on one side ; or high up behind, to- 
wards the sacrum: and we rectify its position, if need 
be, by changing the situation of the mother to her 
back, or to either side, accordingly as we may judge 
most fitting to bring the mouth of the womb into its 
proper place. Thus, suppose the mouth of the womb 
inclined altogether to the right side of the pelvis, 
the patient being on her left side ; let her turn on to her 
back, or quite over to her right side, and the axis of the 
womb will be brought more nearly to the middle line or 
axis of the pelvic canal. 

We are, also, in this operation, to form an opinion as 
to the probable resistance to be made by the vagina, 
perineum and labia, so as to make up our prognosis, 
which it is best, however, to keep as a secret, not to be 



320 ON THE POSITIONS OF THE HEAD, 

divulged for the present. At length, the pains having 
opened the os uteri to the greatest extent, and driven 
down the bag or bladder of waters almost to the orifice, 
the membranes burst, and the fluid of the ovum escapes 
with a gush. As soon as practicable after the escape of 
the liquor amnii, the touching should be repeated, and 
now there is little difficulty in determining the position 
of the head. 

In general, that side of the pelvis in which the head 
can be felt at the lowest level, is the one to which the 
vertex points — for the head already dips, in order to en- 
ter the bony canal. But if, upon feeling the scalp with a 
finger firmly pressed upon it, a suture is discovered, which, 
upon being traced, is found to meet with two other 
sutures, and no more ; that point of union will be the 
posterior fontanel or vertex ; and it wiilbe in the first posi- 
tion if it be near the left acetabulum, in the second posi- 
tion if it be found near the right acetabulum, and in the 
third position if it be directly behind the symphysis of the 
pubis. But if, instead of three sutures, there be four, with 
a large membranous or soft space betwixt their points of 
union, it will be the anterior fontanel ; and if it be near 
the left acetabulum, the head will be in the fourth position, 
in the fifth if it be to the right acetabulum, and in the 
sixth if it be near the pubis. 

I have known many young students to be exceedingly 
embarrassed by being compelled to learn by heart a 
great many divisions and distinctions which are purely 
artificial. Such a student would naturally suppose that, 
if there be but six positions of tlie vertex, each solemnly 
numbered from one to six, no labour could take place 
with the vertex in any other attitude. But he should 
understand, that, if his professor or teacher chooses to 
make twenty varieties of the vertex positions, or another 
man pleases to reduce them to only four varieties, each 
one of those cardinal attitudes is capable of being greatly 
varied so as to cause it to approach near to the one next 
in order, or to be more remote from it. In fact, the 
head may descend so that its point may be directed to 
any part of the pelvic circle ; and, if men have chosen to 
say that there are only six positions, it is not because there 



AND THEIR MECHANISM, IN LABOUR. 221 

are no more than six cardinal points of the pelvis, but 
because they thought that all the other possible attitudes 
could be referred to some one of the legitimate six. Thus, 
I may have a case whicli I should call the fifth position of 
the vertex, and yet the vertex may incline back so much 
as to be almost worthy of being called a sixth, or it may be 
turned forward so far as to be almost a first position. In 
truth, wo shall generally be able to discover, if we ex- 
amine early in labour, that the position of the head is 
by no means a fixed one, because, if the child is alive, 
it is always endeavouring to move the head, turning it to 
the right or the left, and thus causing the vertex to 
sweep round a fourth, or even a half of the circle of the 
superior strait ; and this frequent rotation of the child's 
head continues until it is driven down so far as to be 
restrained from spontaneous motions, either by the nar- 
rowness of the bony passages, or by the contractions and 
resistance of the soft tissues. In all cases, the head 
should be considered as movable at the will of the liv- 
ing child, until it is engaged in the strait, by which en- 
gagement is understood, its having fairly entered into the 
bony pelvis. In whatever labours the head of the fcetus is 
very small, as compared with the size of the pelvis, the 
power of boring with the head, or rotating it, continues 
even to a very late stage of the process of parturition. 
I have very frequently had occasion to note the boring 
or rotary motion of the child's head, after it has fully 
passed the superior strait, and occupied the excavation. 
I should be quite incapable of asserting, in such in- 
stances, that the position is or is not the first, the fifth, 
the third, &c., &c., for it might be each by turns, and 
neither of them long. There is no difliculty of referring 
the case to one of the cardinal positions, in all tliose 
labours wherein the child's head is large, or the pelvis 
small, for in such labours it is fixed. 

I ought to observe here that the student should make 
a careful distinction betwixt the words presentation 
and position. The former refers only to the part that 
presents itself to the passages, and the latter to the direction 
which the presentation assumes. There is a presentation 
of the feet, the shoulder, the breech, the vertex, the face, 
T* 



222 ON THE POSITIONS OF THE HEAD, 

the hand, <fcc., but each of these presenting parts may take 
various positions. For example, the vertex, when it is 
the presenting part, is most commonly found towards the 
left groin, or rather, it is opposite the left acetabulum. 
To chow the comparative frequency of this position, I 
have it to say, that, in supervising twenty thousand 
five hundred and seventeen labours, Madame Boivin, 
who is at tlie head of the Materniie Lying-in Hospital, 
at Paris, found fifteen thousand six hundred and ninety- 
three cases in which the vertex presented in the above 
mentioned position ; whereas, she found that in only 
three thousand six hundred and eighty-two of tlie cases, 
did the vertex present towards the right groin. 

Those who have written or taught upon the subject 
of the positions of tiie vertex in labour, have concurred 
in calling that the first position in which the vertex is 
towards the left acetabulum. It is first, because it is 
most frequently met with. The second posiiion is that 
in which the vertex is turned towards the right acetabu- 
lum, and the third is that in wliich the point of the head 
is behind the symphysis of the pubis. These three are 
well defined as occipito-anterior positions. In the re- 
maining three positions, the forehead is towards tlie 
front, and the vertex towards the posterior part of the 
pelvis, the attitude of the head being the reverse of the 
-first three ; and, therefore, they are occipito-posterior 
positions. The enumeration proceeds from the third 
to the fourth position, in which the vertex is pointed 
towards the right sacro-iliac junction ; the fifth, where 
it is towards the left junction of the ilium and sacrum ; 
and lastly, and, I may add, most rarely, the sixth posi- 
tion, where the vertex is towards the promontory, and 
the forehead beliind the symphysis. 

M. Fiamant, and many others, contend that we ought to 
acknowledjje two other original vertex positions, viz., 
one in whicii the posterior fontanel is to the left ischium, 
the head being transversely disposed in the pelvis, and 
the other in which it is turned towards the right ischium. 
I should not be at all indisposed to adopt eight instead 
of only six cardinal positions, especially as I find that a 



AND THEIR MECHANISM, IN LABOUR. 223 

great many cases do present the vertex in one of these 
latter ways. 

Upon reflecting on the greater frequency of the occi- 
pito-anterior positions, it appears to me not to be diffi- 
cult to explain the reason why the head in labour is so 
commonly presented in that manner, rather than in the 
contrary way. 

The child, in utero, naturally lies on its back, with 
the liead inclined downwards towards the orifice of the 
womb. The longitudinal axis of the womb, at the close 
of pregnancy, and especially at the commencement of 
labour, dips at an angle of about forty-five degrees to- 
wards the horizon, in a woman who is standing or sitting 
up. The child, which is in a complete state of flexion, 
both as to its body and its limbs, would naturally roll in the 
waters in such a manner as to permit its back to fall 
lowest, and fill up the concavity of the anterior paries 
of the uterus, v;hile that organ is itself resting on the 
abdominal muscles, which it protrudes before it, and 
which form a soft and elastic cushion for it. 

The disposition which the parturient woman has, dur- 
ing the early pains, to stoop or lean forwards, could not 
fail to bring the child nearer to a horizontal position, and 
thus still more greatly favour its tendency to roll upon 
its back ; so that, when the head comes, at last, to en- 
gage in the circle of the superior strait, its point will be 
turned somewhat towards the pubis, or front of the pel- 
vis, i. e. it will assume an occipito-anterior position. 
If this view be admittoil as correct, then it will be 
highly proper to permit the woman to sit up as much as 
she pleases in the early stages of the labour, or until 
the head is engaged so far as to make it improbable that 
it can continue to roll freely in the waters. Further, as 
it is generally better that the head should be presented 
in the first position, the patient ought to be advised to lie, 
when she is on the bed, upon the left side, in order that 
the child's back, by falling into the lowest concavity of 
the womb, may cause the occiput to direct itself towards 
the left side of the pelvis. 

In a good many cases, however, the forehead occu- 
pies the place that ought to belong to the occiput, and 



224 ox THE POSITIONS OF THE HEAD, 

there are many reasons why such, a reversal of the 
posture should occur: among others might be mentioned 
the habit of lying upon the back ; a degree of restless- 
ness, which, by causing the woman to change her posi- 
tion frequently, might prevent the foetus from settling 
down in the proper direction ; or the spontaneous 
movements of the child, which are sometimes very 
strong, and which, by rotating the head, might very 
readily occasion it, at last, to present in an occipito- 
posterior position. If, when this position is discovered, 
the woman is not lying upon her side, she should be 
advised to do so, as the proneness of the head to revolve, 
cannot be expected to produce a favourable change, 
unless the attitude of the patient should be so judiciously 
prescribed as to promote or facilitate that change. 

Any attempt, except one made by means of regu- 
lating the posture of the patient, must fail to effect a 
change in the position of the head, in the early stages of a 
labour : w^e cannot act upon the head until the waters 
are gone off; nor is it allowable to break through the 
ovum, under these circumstances, until a great dilatation 
of the OS uteri is effected ; for the desirable rotation can- 
not be brouglit to pass near so well in a completely con- 
tracted womb, as in one where an abundance of waters 
permits the body of the child to turn freely on its axis, 
and conformably to the mutation of the head's position. 
Hence, it generally happens, that incases of occipito- 
posterior position the labour proceeds without rotation 
until the os uteri is fully dilated, and the head descends 
so low as to begin to press upon the floor of the pelvis. 
But in order to get thus far, more time and pain are 
required than in occipito-anterior positions, cseteris 
paribus. 

The vertex, when it is directed towards the back part 
of the pelvis, enters very readily into the superior strait, 
and descends under and behind the brim, towards the 
wing of the sacrum. Indeed, in some instances of 
labour, the head engages in this way even more rapidly 
and easily than in the occipito-anterior positions, and 
the attendant, seeing the rapid progress of the head, 
is very liable to make a false prognosis, by promising 



AND THEIR MECHANISM, IN LABOUR. 225 

an early delivery, in which he is egregiously disap- 
pointed in consequence of the difficulties to be after- 
wards encountered. 

These difficulties arise from two causes : first, the 
greater dilatation of the os uteri required in this position; 
and, second, the tedious process of a rotation, double in 
extent to that demanded in a first or second position. 
When the vertex is to the front, it enters the os uteri fa- 
vourably, and the whole head passes through that orifice 
presenting to the uterine circle its smallest circumference, 
or that which, passing over the crown of the head, the 
base of the scull and the parietal protuberances, consti- 
tutes a circumference of ten inches and a half, or a circle 
of three and a half inches diameter. Such a dilatation 
is sufficient to allow the head to escape into the vagina, 
which, again, must be dilated to an equal extent and not 
more, and so of the vulva, which attains with much 
resistance the required dilatation ; but when the vertex, 
on the other hand, descends in a posterior direction, the 
OS uteri must open sufficiently to embrace the horizon- 
tal circumference of the head, which passes round the 
head, beginning at the forehead, embracing the parietal 
protuberances, and enclosing the vertex, which will be 
a circle of twelve and a half or thirteen inches in cir- 
cumference. A similar degree of distension is required 
for the vagina and for the vulva ; which manifestly 
will demand more time, and cause much more pain than 
the first position case. 

The other reason why these labours are not so favour- 
able is, that a much greater rotation is necessary, if that, 
indeed, can be brought to pass at all, and a most violent 
flexion of the head, where the rotation fails. Let us sup- 
pose that the vertex enters the pelvis in contact with the 
upper part of the right sacro-iliac symphysis. The face 
and body of the child look towards the left acetabulum, 
and the side of the abdomen. The chin is strongly pressed 
against the breast, and the vertex is at a much lower 
point than the top of the forehead, or, in other words, 
the occipito-frontal diameter of the head dips from before 
backwards, from above downwards, and from left to 
right. It is the occipital extremity of this diameter that 



226 ON THE POSITIONS OF THE HEAD, 

soon meets with an obstacle to its progress, for it 
comes to abut directly upon the curved surface of the 
bone, towards the lower and back part of the pelvis, or 
upon the elastic inclined plane composed of the sacro- 
sciatic ligaments. While it is driven against these 
obstacles with greater or less impetuosity, the frontal 
extremity of the diameter seems to repose or lean against 
the opposite and superior portion of the pelvis. It some- 
times happens that the vertex is propelled against this 
obstacle for hours in vain, producing a total arrest of the 
head, and even, at last, jamming the forehead down on the 
opposite side of the pelvis, until it becomes immovably 
fixed or impacted there. But, fortunately, such is the 
admirable construction of these surfaces, that it most 
frequently happens that the vertex slides off towards the 
lower part of the ischium, until the head is fixed trans- 
versely in the pelvis, and, at last repelled by the inclined 
plane of the ischium, continues to slide forwards and 
downwards until it comes under the pubal arch, from un- 
der the crown of which it emerges, rising towards the 
pubis, as it escapes, and allowing the head to extend 
itself so as completely to remove the flexion, which, as 
it was the first foetal movement in labour, so the recovery 
from it is the last. 

This is the most common and most favourable occur- 
rence in the occipito-posterior positions. Where that 
fails to happen, the vertex slides backwards into the 
hollow of the sacrum, and the head is placed in an an- 
tero-posterior direction. Under these circumstances, the 
occipito-frontal diameter is so long, that either the vertex 
or the forehead must soon get lowest. In a common sized 
child, the forehead cannot get down, therefore the ver- 
tex moves slowly and painfully down the middle of the 
sacrum, over the coccyx and the perineum, pushing the 
latter out most enormously, and elongating the labia ma- 
jora until they acquire dimensions sufficient, or break off*. 
The vertex at last reaches the edge of the perineum, and 
escapes over it, whereupon the head begins to extend 
itself backwards towards the sacrum ; lastly, the fore- 
head, eyes, nose, mouth and chin enter in succession 
under the arch, and the child's head is completely born. 



AND THEIR MECHANISM, IN LABOUR. 227 

It is difficult to imagine how a child can escape death in 
such a labour ; nevertheless we find that some are born 
so without any very alarming delay or difficulty. 

The pure specimens of third and sixth positions are 
supposed to be very rarely met with. The intrusion 
of the promontory and the lumbar vertebrae, are the 
causes why the head enters obliquely ; but I think Ma- 
dame Boivin and Madame Lachapelle would have seen 
more specimens than they have recorded, had they been 
diligent in their searches for it at an early stage, in the 
sixty thousand labours they have superintended. 

It is quite true that the convex surface, either of the 
vertex or of the forehead, would easily slide off from 
the convex projection of the sacrum : yet I am sure that 
the circular or horizontal contraction of the cervix uteri 
does sometimes grasp the head so firmly as to hold it 
fast in any position in which it might happen to be se- 
cured; and I have attended one person, in two of her 
labours, in both of which the vertex was, at an early 
stage, in the hollow of the sacrum, and the great fontanel 
behind the pubis, the child being delivered with the ver- 
tex at the fourchette. I inferred that the presentation 
was an original sixth position. 

If the vertex presents in the first position, and, after the 
proper rotation, comes to emerge under the arch of the 
pubis, the right shoulder of the child will enter the pelvis 
near the right acetabulum, and the left one in the left 
sacro-iliac region, the shoulders assuming a diagonal 
position, the reverse of that taken by the head. As soon 
as the head escapes from the external organs, the shoul- 
ders, descending into the excavation, are compelled to 
undergo a rotation, by which the right shoulder tends 
forwards towards the arch of the pubis, and the left one 
falls backwards to the hollow of the sacrum. In a ma- 
jority of instances, the shoulder that is nearest the sacrum 
descends more rapidly than the other, and escapes first, 
soon after which the right shoulder emerges, and the 
body is afterwards speedily expelled. 



CHAPTER XIV 



ON PRESENTATIONS OF THE PELVIC 
EXTREMITY OF THE FOETUS. 



As the length of the gravid uterus, at full term, does 
not exceed twelve inches, and as a well grown foetus 
is nineteen or twenty inches in length, it is evident that it 
must, while in utero, be folded up in a very compact 
form, and that it will be an oval body, one of the 
extremities of which ought to be directed towards the 
orifice of the womb, and the other to the fundus. The 
natural position of the foetus is certainly that in which 
the head points downwards ; so that the vertex, or some 
part of the head ought to advance first. But it happens 
that about one in every forty-five or fifty cases presents 
the other extreme of the oval to the os uteri ; and in 
doing so, it is a matter of mere chance whether the 
breech, or the knees, or the feet, prove to be the pre- 
senting part. In strictness, the breech ought to descend 
first in these labours, but if the feet happen to be near 
when the membranes give way, they are quite likely to 
fall into the opening, and pass, soon afterwards, out at 
the vulva; so that, supposing the breech presentation to 
be, after those of the vertex, the most natural, we may 
properly include in the account of the presentations of 
the pelvic extremity, those of the knees and feet, and 
regard them as mere accidents of the pelvic presentations, 
and all to be included under the head of natural labours. 

It is not an easy matter to determine wliy the breech 
presentation occurs about once in forty-five or fifty 



ON PRESENTATIONS, ETC. 229 

labours, and it is far less easy to say what is the reason 
that certain women are prone to this sort of labour to 
such a degree as to bring all their children so. I knew 
a lady whose children, three in number, were all born 
with the breech presentation, and it is by no means very 
rare to meet with persons who have been similarly 
situated in more than one of their labours. Dr Collins, 
of Dublin, in his recent valuable work on Practical Mid- 
wifery, informs us, that one woman who was delivered 
at the Dublin Lying-in Hospital had preternatural pre- 
sentations in every one of her labours, and she had 
given birth to nine children. While that gentleman was 
master of Dviblin hospital, sixteen thousand four hundred 
and fourteen women were delivered, of whom three 
hundred and sixty-nine had presentations of the breech, 
feet or knees ; making rather more than one such 
labour, in every forty-five cases. 

The causes which produce these presentations must 
be purely accidental. The natural presentation is that 
of the head, which is turned towards the os uteri from 
the earliest period of pregnancy. The attachment of the 
navel string is nearer to the pelvis than to the head of 
the child, the head therefore hangs downwards ; but 
when the cord, by the growth of the ovum, has become 
of a very considerable length, the child ceases to be de- 
pendent from it, for the cord is not unfrequently from 
twenty to thirty inches long. It seems very probable 
that while the fostus is yet small, it may change its po- 
sition in the uterus ; but if it happen to turn as late as 
the fifth month, it will be apt to retain the attitude it 
may then acquire, till the end of the pregnancy, as its 
length does not admit of its changing again very readily 
after that period. It is not to be doubted, however, that 
the attitude may be reversed, by certain extraordinary or 
violent movements of the mother, at a later period, so that 
the head, which was originally at the os uteri, may be 
brought to the fundus, and vice versa. 

Notwithstanding that the breech presentation is met 

with only once in forty-five or fifty labours, I am not 

inclined to regard it as a preternatural case, for I cannot 

discover any reasons for classifying it with that sort of 

u 



230 ON PRESENTATIONS OF THE 

births, ill the mere fact that the head does not present. 
The breech composes one of the ends of the foetal oval ; 
and a breech labour requires, for its complete success, no 
greater dilatation than that demanded for the passage of 
the head. It may be effected without any aid, and is, 
perhaps, not really fraught with greater danger for the 
mother than the other, or more common vertex presenta- 
tion. It is, however, far more dangerous for the child 
than the vertex case; and as the object of parturition is 
the safe birth of the infant, ft might be absolutely proper 
to include, in the class of preternatural labours, all those 
in which the cliild is exposed to unusual hazard. 

The danger to the child, here, depends on its liability to 
asphyxia, from several causes : first, the compression of 
the cord, v/liich is pressed betwixt the child and the 
parts from which it is escaping ; second, detachment 
of the placenta before the head is born, by whicli the 
uterine life of the child is destroyed before its birth ; and 
lastly, the compression of the placenta itself beiwixt 
the uterine parietes and the head of the infant, or the 
constriction of the placental superficies of the womb 
during the time tliat the child's head, still remaining in 
the vagina, and lingering there, ceases to distend the 
uterus, which tlier. closely contracts on the afterbirth, 
and even if still retaining its connexion with it, yet sus- 
pends all the utero-placental operations on which the 
foetus depends for existence, antecedently to the esta- 
blishment of respiration. The breech may descend into 
the excavation, and it may even pass through the vulva, 
without tlie least danger of compressing the cord ; but 
when the body of the child has sunk so low as to bring 
its navel down into the bony pelvis, there is danger that 
the arteries of the cord may be completely obstructed for a 
period long enough to give the child a fatal asphyxia, 
an event far more likely to occur where the feet present 
than where the breech advances ; because, in the latter 
case, the thighs, and sometimes the legs, are extended 
along the front of the body in such a manner as to pro- 
tect the cord from pressure, that part being fully guarded, 
by its position betwixt ihe thighs, during all the time the 
body is escapiiig, and thus enabling the infant better to bear 



PELVIC EXTREMITY OF THE FCETUS. 231 

the temporary pressure on the cord, for the short time it 
is compressed only by the head, while that part is in the 
excavation ; a pressure, that would extinguish a life that 
was already about to expire from a long continued pre- 
ceding pressure by the child's body. In general, the 
danger for the child is not great until the head has sunk 
down into the excavation, because it commonly does not 
take a great deal of time for the whole of the body to 
pass through the canal of the pelvis ; but the head, being 
subject to arrest while in the passage, may then fatally 
compress the cord betvvixt itself and the bony sides of the 
pelvis. 

I think it probable that more than one child in every 
five that presents by the breech, or feet, or knees, pe- 
rishes in the birth. In large lying-in hospitals, perhaps, 
the proportion of fatal cases is rather more favourable, in 
consequence of the prompt attention always paid in such 
establishments to the parturient female, and to the greater 
skill and dexterity acquired by abundant opportunities of 
practice. 

It is a question whether the nature of the presentation 
can be discovered by reference only to the movements 
of the foetus in the latter stages of gestation. Some 
persons have foretold that the child was improperly 
placed, judging it so to be by feeling a greater degree of 
motion in the pelvic region than in the upper part of the 
uterus. It seems not difficult to believe that if the 
motions of the child should be chiefly felt towards the 
cervix uteri, they ought to be accounted for by referring 
them to the presence of the feet in that quarter. How- 
ever, I feel assured that those patients whom I have 
attended, and whose labours were accompanied with this 
presentation, were utterly unsuspicious of it in pregnancy ; 
and are, generally, ignorant of it until the child is born. It 
is not uncommon, indeed, for women to fear that the 
child is to be born double, as it is called, when the vertex 
really does present ; and some patients are quite con- 
vinced the child is wrongly placed until labour comes on 
to prove their fears ill founded. There maybe some 
certainty, perhaps, of a diagnosis derived from the stetho- 
scope applied to different parts of the uterine region, for 



232 ON PRESENTATIONS OF THE 

if the child's head be directed towards the fundus uteri, 
there will be, in consequence, a pulsation of its heart at 
a higher level than if the head occupy its more natural 
position — probably near the navel ; but there will always 
remain some liability to wrong impressions, if they be 
derived from auscultation alone. The surest way is 
that of the touch, which is scarcely to be confided in 
except at the commencement of labour, or at a period 
when the presentation can be touched with the tip of 
the finger. 

When the breech can be reached per vaginam, it 
ought to be recognised by its mass, filling up the pelvis ; 
by its softness, and its fleshy feel, so different from that 
of the foetal head ; by the tubera ischii ; by the point of 
the coccyx, the anus, and the organs of generation, 
male or female ; by the spines of the sacrum, and by the 
sulcus found between the nates and the thighs, which 
tend upwards from the presenting part — I may add, also, 
by the meconium which is often discharged at a pretty 
early stage of labour, and comes away with the waters, 
on the hand of the accoucheur ; but let not the young 
accoucheur be deceived by this symptom, since it is 
possible for portions of the meconium to come away 
even in the best vertex position. It is also to be ob- 
served, that the form of the bag of waters is commonly 
not so much like a segment of a sphere in the presenta- 
tions of other parts than the head. In breech presenta- 
tions, it is more like an intestine in shape, sometimes 
descending to the very orifice of the vagina, and yet not 
very considerably dilating that passage. 

Notwithstanding we ought to be able clearly to dis- 
tinguish betwixt the breech and the head presentations 
by the first touch, it is, I think, not very uncommon for 
us to make a very great mistake, if I may judge from the 
instances of mistakes that have come under my know- 
ledge ; but I am very sure that such errors are the results 
of mere carelessness, and they should therefore be always 
avoided. Let it not be here understood that when the 
true nature of the presentation is known it ought to be 
communicated to the patient ; on the contrary, it should 
be carefully concealed from her, as not calculated to pro- 



PELVIC EXTREMITY OF THE F(ETUS. 233 

/ 

mote her easy deliverance, since she attaches to the cir- 
cumstance the idea of greater sulTering or danger, which, 
by depressing the powers of her mind, would be very- 
apt to affect, in an injurious manner, the pains, or the 
voluntary efibrts that she ought to have in their greatest 
vigour. While the nature of the case, then, is carefully 
concealed from the patient, it should be formally an- 
nounced to her husband, or to some responsible person, 
and all the hazards of such a situation for the infant 
should be explained, in order that if any untoward event 
should cause the infant to be stillborn, no unjust impu- 
tations might lie against the candour, the skill or dex- 
terity of the accouclieur. 

When the breech is found to be the presenting part, it 
is very natural to suppose that, could the feet be brought 
down, they would give us the command of the child, so 
that we could very greatly assist in its delivery ; and 
this is quite true : nevertheless, it is bad practice to 
bring the feet into tlie vagina, except for some very well 
understood and sufficient cause. When the child de- 
scends double, as it is called, the parts yield very slowly 
for its advance, and this tediousness is a necessary con- 
sequence of its bulk, and the yielding nature of its struc- 
ture : unlike the head, which is hard and firm, this part, 
when urged downwards by the pains, gives way before 
them, and is compressed so much that each pain is half 
lost before the part becomes firm or condensed enough 
to make it act as a dilater. This slowness is greatly to 
be deprecated ; and all proper means to obviate it may 
be safely resorted to, such as a venesection, or the ad- 
ministration of a clyster, or a dose of castor oil, &:c. ; yet 
this very slowness, and the great size of the breech, 
serve as means for the child's security at the last mo- 
ments of labour. By their means the os uteri, vagina 
and vulva are so completely opened, and so entirely de- 
prived of the power of resisting, that, when the head 
comes to take the place of the body in the excavation, a 
very little force of the woman's straining serves to extri- 
cate the head, or at least the complete dilatation enables 
the accoucheur to employ his hand or his forceps to 
extract the head in time to save the child from an 



234 ON PRESENTATIONS OF THE 

asphyxia, which is almost sure to affect children that 
are not born very soon after the escape of the shoulders ; 
because, during the time the head is in the vagina, the 
cord must be severely compressed ; and even if it were 
safely put away in one of the sacro-iliac spaces, the 
placenta would, by this time, be so completely squeezed 
by, or even separated from, the womb, that the utero- 
placental functions would naturally cease to be per- 
formed. 

The impatience, which can scarcely be avoided by 
persons witnessing the throes of the mother, or the 
struggles of the child, also exposes us to the danger of 
doing it a great harm by pulling strongly by the breech, 
shoulders, (fee. in order to get both mother and infant the 
more speedily released ; but if any one will take the time 
to reflect that the spinal marrow may be greatly injured 
by a violent extension of the neck, it will be evident to 
him that no very great amount of extracting force ought 
to be applied. It is best, therefore, as a general rule, to 
permit the breech to descend, and not in any manner to 
interfere with the feet until they are spontaneously born. 
Any extracting force has an invariable tendency to slip 
the arms upwards, so as greatly to embarrass the last 
and most im.portant act of the breech labour. When 
the child is wholly expelled by the uterine contraction, 
it is pushed out of the womb in consequence of the 
approach of the fundus to the cervix of that organ. In 
that natural process, if the arms happen to be resting on 
the sides or abdomen of the child, they ought to descend 
pari passu with the parts on which they rest; but if the 
child be pulled out, then, as the fundus uteri does not 
press with a proper power upon the head, the arms will 
naturally slip up over or along-side of its head, where 
they sometimes are so firmly fixed as to make it a very 
difficult matter to bring them down. Hence the sound- 
est discretion teaches us to let the womb push forth the 
breech as we let it push forth the head, without laying 
hold of it to drag it downwards as soon as the least 
purchase can be had on the presenting part. 

The legs, in a breech presentation, may be turned 
upwards on the child's belly, or they may be flexed on 




835 



PELVIC EXTREMITY OF THE FCETUS. 235 

the thighs, so as to bring the feet very near the nates. 
If the breech engages in tlie pelvis, or begins to pass 
the circle of the os uteri, the feet disappear, rising as the 
nates descend. There is no danger of injury to the hip 
or knee joint, if the child be trusted to the natural powers 
employed for its birth or expulsion ; but whenever much 
force is employed by putting the fingers in the groin, 
we do incur the hazard of breaking or dislocating the 
thighs. 

The breech may have one of four positions : 1st. The 
child's back to the left acetabulum of the mother ; 2d. 
To the right acetabulum ; 3d. To the pubis ; and 4th. 
To the promontory. These several positions are easily 
discriminated in practice by the touch, which ought not 
to mislead any attentive or considerate practitioner, since 
by the touch it is easy to learn where is the coccyx, the 
tiibera ischii, the genitals, the sulcus betwixt the thighs, 
the sacrum, &c., &:c. 

As the escape of the breech occasions a great disten- 
sion, the perineum requires very steady support by press- 
ing a soft napkin against it, for the purpose, first, of 
resisting the too rapid advance of the breech, and second, 
in order to give to its movement that curvilinear direction 
which ushers it into the world, in a course parallel with 
the line or axis of the pelvis. As soon as the body is 
so far born as to permit the navel string to be reached, 
it is to be drawn downwards a little, so as to free it from 
the danger of being broken off, or the greater danger of a 
too early detachment of the placenta. It is easy to draw 
a considerable loop of it downwards by pulling at the 
yielding portion. As soon as the feet are delivered and 
extended, they, as well as the body, should be wrapped 
in a napkin, in order that the skin may not sufi'er any 
injury, and also for the purpose of enabling the accou- 
cheur to hold it more firmly, vv^hich he could not other- 
wise do on account of the viscous nature of the substances 
that adhere to it soon after it emerges. 

In the first position of the breech, the child's left hip 
should rotate towards the pubis, so as to allow the sacrum 
to glide down along the ischium, and the right hip to 
fall into the hollow of the sacrum. But after the hips 



236 ON PRESENTATIONS OF THE 

are fully delivered, they recover the obliquity of their 
former situation, and the body continues to descend so, 
until the shoulders, entering into the pelvis in an oblique 
direction, come to rotate as did the hips, the left shoul- 
der advancing to the pubis, aiid the right one falling 
back into the hollow of the sacrum. When the shoul- 
ders do not come down well, a finger should be passed 
up so far as to reach above the one that is nearest at 
hand, and depress it by drawing it along with the finger, 
which commonly sufiices to cause the arm to escape. 
But if the arm does not descend readily, let the finger be 
slid along its upper surface to a spot as near as may be 
to the bend of the elbow, and then the elbow may be 
drawn downwards with a considerable force, and with- 
out any danger of fracturing the os humeri. One arm 
having escaped, there will be little difiiculty or delay in 
getting the other down, especially if care be taken to 
move the body in a line of direction opposite to that 
part where the arm is detained. 

As soon as the arms are delivered, an examination 
should be made in order to learn how the head is situ- 
ated. If the face is found in the hollow of the sacrum, 
and the chin well down towards the fourchette, it is 
well. The child's body ought now to be raised upwards 
on the practitioner's arm, to a height sufficient to enable 
the longest axis of the head to become parallel with the 
axis of the vagina, and the patient pressingly exhorted 
to bear down and force the child out of the passage, for 
at this time the head is not in the womb, but in the 
vagina, and for its expulsion there is required rather the 
effort of the abdominal muscles than that of the uterus, 
Vv^hich doubtless does, in many instances, partially close 
its orifice above the vertex, in this stage of a footling or 
breech case. If the patient therefore does not make a 
very great efl^'ort of bearing down, or expulsion, the head 
must remain in the passage, during all which time the 
child is exposed to the risk of perishing by asphyxia. 
It is true that the pressure of the head upon the parts 
tends to pi ^duce a very violent tenesmus, which "com- 
pels the woman to strain very much ; but it is also true 
that in some instances she will not make the smallest 



PELVIC EXTREMITY OF THE FCETUS. 237 

effort, unless urged or commanded in the most earnest 
manner by the physician. 

Some aid may be given at this critical moment by 
drawing the child downwards, but the attendant should 
always carefully reflect, while employing any extractive 
force, that the child's neck will not bear a great deal of 
pulling, without the most destructive effects on the 
spinal marrow. Certain it is that the infant in the birth 
will not safely bear more force applied to its neck than 
one after the birth, a reflection that ought to regulate the 
physician always. 

If all his exhortations fail of causing the woman to 
assist him by bearing down, let him endeavour to pre- 
serve the child from suffocation by passing two of his 
fingers upwards until they reach the two maxillary bones, 
and cover the nose ; by doing this the backs of the 
fingers, pressing the perineum backwards, serve to keep 
an open communication with the air, and the child can 
breathe very well until the tenesmus comes on. I have 
kept a child alive in this way, breathing and sometimes 
crying, for twenty or twenty-five minutes before the 
birth of the head, and thereby saved a life that must have 
been lost but for this care. At last the head descends 
and escapes from the vulva very suddenly, after which 
the placenta having been duly attended to, the delivery 
is complete ; whereupon the lady may be put to bed. 

A few years ago I was engaged to attend a young 
lady in her first childbirth. When she fell in labour, I 
discovered that the breech presented. Her residence 
was about three-fourths of a mile from my house. I 
was very much inclined to send for my forceps, for fear 
that when the head should come at last to occupy the 
vagina, I might be unable speedily to deliver it. But as 
she was exceedingly delicate and timid, and her friends 
anxious, I deferred sending for them lest alarm should 
be the consequence of bringing them to the house. The 
labour proceeded very favourably until the shoulders 
were free, and then, notwithstanding the head took the 
most favourable position, I found that no exhortations 
or entreaties could suffice to make the lady bear down, 
and the child soon became threatened with asphyxia, 



238 ON PRESENTATIONS OF THE 

which I obviated by admitting the air freely to its mouth 
and nostrils, by pressing off the perineum. The child 
cried, and I felt a hope that the forceps, which I now 
sent for, would arrive in time for its succour. The in- 
struments were placed in my hands in the shortest time 
possible. In two minutes after I received them they 
were applied, and the head withdrawn, but it was too 
late to resuscitate the child. I have never since failed 
to order my forceps to be placed within my reach in 
any case of footling or breech labour, and I feel well 
assured that the consequence of this care has been the 
saving of several lives that must have been lost but for 
this precaution. I have lost but one child in pelvic pre- 
sentation in the last three years, and that was one which 
was a vertex case, but which I brought footling in con- 
sequence of hemorrhage from placenta praevia, and in 
M^iich I was obliged to deliver the head with the forceps, 
as the lady was so exhausted by loss of blood that she 
could not bear down. 

It is my unfailing custom, therefore, to order my for- 
ceps to be put in readiness as soon as I ascertain that the 
presentation is not one of the head ; and I feel very well 
assured that such a precaution, if generally observed 
would preserve many a life that is now lost, either by 
delay in the delivery of the head, or by pernicious at- 
tempts to extract by pulling at the neck, to which the 
temptation is so strong in moments of great anxiety for 
both parent and offspring. 



In those cases in which the sacrum of the child is di- 
rected towards the mother's back, it is highly desirable 
so to conduct the labour as to effect a complete rotation 
of the child by tlie time the head begins to get pretty low 
in the excavation. If this change does not take place 
spontaneously, or by the skilful interference of the ac- 
coucheur, it must happen, at the last and important stage, 
that the face will be to the pubis, and then there will be 
some difficulty in obtaining the requisite dip of the head 
or its due flexion. It is exceedingly dangerous for the 



PELVIC EXTREMITY OF THE F(ETUS. 239 

child to be so situated, but happily there is a method by 
"vvhich it may be hopefully assisted. 

As soon as the shoulders are fairly freed from the 
vulva, the edge of the perineum tends to compress the 
neck of the child, and force it upwards against the arch 
of the pubis. In some cases the perineum is so strong 
or elastic as to exert a considerable power in this way ; 
and it is clear that if it be not counteracted, the chin may 
be lodged upon the top of the symphysis of the pubis, 
and wholly prevent the flexion of the head from taking 
place. Under such circumstances the child will spee- 
dily perish. The indication is then to push the peri- 
neum back again, or carry the child far back towards 
the coccyx, and afford space enough to let the chin de- 
scend, either spontaneously, or by pulling it down by 
introducing t!ie fore and middle fingers of the right hand 
into the child's mouth. As soon as the chin is well 
brought down, the woman should use all her power to 
assist in the expulsion of the head. I have found that 
the best attitude for the mother, in this kind of delivery, 
is that which is advised for forceps operations, to wit, 
that in which she is placed on her back, with the hips 
brought quite over the edge of the bed, the feet being 
supported by two assistants ; so that, when the shoul- 
ders are delivered, the child may be supported almost in 
a vertical posture by the left hand of the accoucheur, 
while his right hand aids in the delivery of the head. I 
am sure that much greater command of the labour may 
be had in this position of the patient than in any other 
that can be devised. 

But, as I have already observed, we should endeavour 
to manage the case so as to get the face into the hollow 
of the sacrum, instead of letting the chin come to the 
pubis. If, therefore, the breech sink into the excava- 
tion in this unfavourable manner, we should, by pressure 
with two or three fingers, endeavour to force that hip 
which is nearest the front towards the symphysis, and 
if we succeed in effecting its delivery in that position, 
we should, with a proper degree of force, continue to 
turn the forward hip more and more round, so as to 
bring the child's spine at least as far in front as the 



240 ON PRESENTATIONS OF THE 

ramus of the ischium or pubis ; so that when the shoul- 
ders begin to enter, they may enter obliquely, and after 
they have passed down, the head may also enter ob- 
liquely, or at least transversely. For example, let the 
sacrum be towards the mother's back, the child's right 
hip will be on the ri^ht ischium of the mother. We 
might try to get the right hip towards the ramus of the 
ischium, then towards the ramus of the pubis, and, as it 
advances, cause it to emerge just under the arch. When 
fully emerged, the hip should be turned more and more 
to the left of the mother, so as to let the right shoulder 
enter the brim at the left acetabulum, and escape under 
the arch, in doing which, the child's face will enter near 
the left sacro-iliac symphysis, and at last slide into the 
hollow of the sacrum, as in a second position of the 
breech. 

Where this desirable rotation cannot be gently effected 
in consequence of the grasping force of the womb hold- 
ing the child's body tight during a pain, we ought to 
watch for an opportunity, during the absence of a pain, 
to push the child's body upwards again as far as we 
conveniently can, and then draw it downwards, endea- 
vouring, while pulling it downwards, to twist or rotate 
it in tiie manner that is required. 

If, on the other hand, we endeavour to bring the left 
hip to the pubis, we shall also get the left shoulder 
there ; at last, compelhng the face to enter at the right 
sacro-iliac symphysis, we shall terminate the labour in 
the first position of the breech. 

I shall here relate a case taken from my record book, 
which may serve to show the student what a great rota- 
tion may Be effected by the hand of the practitioner, in 
cases of the fourth position. 

Tuesday, October 5th, 1830. Mrs J., a young woman, 
in her first pregnancy, sent for me at eight o'clock P. M. 
The waters came ofi"^ at five o'clock P. M. The os uteri, 
at my arrival, was almost completely opened. I touched 
the breech and feet ; tlie toes were towards the left ace- 
tabulum. At a quarter before nine o'clock 1 disengaged 
tlie right foot, and then the left one. At nine the arms were 
both delivered, the left one escaping first along the peri- 



PELVIC EXTREMITY OF THE FCETUS. 241 

neum and the right one under the pubis. I could not 
effect any further rotation, and was sorry to find the 
chin immediately behind the symphysis pubis. I then 
turned the child's body, and pulling the chin well down- 
wards, I pressed the face with two fingers, on its right side, 
and with great ease turned it into the hollow of the sacrum. 
I next made a channel by passing up two fingers to the 
superior maxilla, so as to admit air freely to the nose, 
and the infant breathed ; there was a total cessation of 
pulsation in the cord. The child breathed and cried at 
least for twenty minutes before the head was expelled, 
which I could not effect until I carried its body upwards 
towards the mother's abdomen, and rolled her over on 
her right side, which gave me far better power to aid her 
with my right hand. The infant was born living, and 
did well. I shall cite another instance wh.ich occurred 
very recently. 

On Thursday, July 14th, 1836, Mrs was seized 

with labour pains, which came on with the rupture of the 
membranes. At six o'clock 1 made an examination, and 
found the left foot in the vagina, accompanied by the um- 
bilical cord, which pulsated. The toes were directed to 
the pubis. I could reach the breech of the child, but 
the right foot was so high up that I could not touch it. 
In a short time the foot came quite down ; and in order to 
rotate the body I drew moderately upon the foot, which 
caused the left hip rapidly to approach the pubis. I could 
not even yet get at the right foot, wherefore I permitted the 
child to descend with that limb pressed upwards against 
the belly ; the left hip came under the centre of the arch, 
and as soon as I could command it, I turned it more and 
more round, so that when the arms were delivered, I 
found the face in the sacrum, soon after which the head 
was expelled. I immediately ascertained, that there was a 
second child ; pains came on, and in fifteen minutes after 
the first one was born, I broke the membranes of the se- 
cond, which presented the nates and the right foot. The 
foot prolapsed, but the other limb was pressed against the 
child's belly, so that I could not get it ; the sacrum was 
to the right acetabulum. When the shoulders were deli- 
vered I found the child's face rather transversely directed 

V 



242 ox PRESENTATIONS OF THE 

towards the left iscliium. I brought it into the hollow 
of the sacrum, soon after which it was also expelled. 
Both children are well. 

It is so easy a matter, in general, to cause the body to 
rotate during its transit through the pelvis, that it very 
rarely happens, if the physician is called early, that the 
face at last is found towards the pubis. 



With regard to the presentations of the feet and knees, 
I do not know that it is necessary for me to enlarge upon 
them, before I close this chapter. I may remark, how- 
ever, that the knee presentation is found to be embar- 
rassing from the tendency there is to a sort of arrest, in 
consequence of the knees abutting against the sides or 
parieles of the pelvis, which is sufficient to prevent the 
descent of the child's nates, so that they, being thereby 
thrust over to the opposite side, cannot enter the excava- 
tion. Ilence, where the knees present, it is advisable to 
convert it into a footling case, which can be done by push- 
ing the whole presentation upwards, during the absence 
of pain, in order to gain space enough to bring down the 
feet. 

The student will perceive, if he refers to the axis of 
the womb and that of the vagina, that in a knee case, in 
which the child's back is towards the left front of the 
mother, the thighs woul'd be very greatly extended, or 
bent backwards, before they could emerge from the exter- 
nal organs ; an extension that must be very difficult to 
efiect where the legs are bent up on the back of the thighs 
— for in such circumstances the rectus feraoris, and in- 
deed the whole quadriceps muscle, must be put exces- 
sively on the stretch. It is a good rule, therefore, in knee 
presentations, to get the feet down as soon as it can be 
prudently done ; whereas in the well defined breech cases, 
the feet ought not to be brought down, except for some 
valid and well understood cause. 

In order to distinguish the feet from the hands, for 
which they are sometimes mistaken, it is only necessary 
to give attention to the sensations imparted by the ope- 



PELVIC EXTREMITY OF THE FCETUS. 243 

ration of touching. The even range of the ends of the 
toes, and their shortness, compared with the length of 
the fingers ; the closeness of the great toe to the one next 
to it, in contrast with the wide separation of the thumb 
from the fore finger ; the ancle, and the heel, are marks 
that might be supposed sufficiently prominent to guard 
us against even the danger of mistake ; yet, very great 
attention is in some instances required, to enable us to 
aver positively that the presenting part is, or is not the 
foot. 

As the footling is but a deviation from the breech 
presentation, its positions are like its original form, viz. 
the heels to the left acetabulum; the heels to the right 
acetabulum ; the heels to the pubis ; and lastly the heels 
to the sacrum. As the treatment is precisely the same 
as in presentations of the nates, I shall not detain the 
reader by any further remarks upon the management of 
them. 



CHAPTER XV 



OF PRETERNATURAL LABOUR. 



Any labour that cannot be brought to a safe conclu- 
sion by the natural powers of the system, might be de- 
nominated a preternatural labour ; and as the causes that 
might prevent the accomplishment of the parturition 
except by the help of art, are very numerous, it follows 
that there are a great many kinds of preternatural labour. 

A labour may be accidentally changed from a natural 
to a preternatural one ; or it may possess a preternatural 
character from the very beginning, and be unavoidably 
so. Thus, a woman may have brought her child almost 
into the world without any appearance of disorder, or 
danger, or uncommon distress, and then suddenly be 
attacked with convulsions, apoplexy, hemorrhage or lace- 
ration of the womb, &c., &c., either of which occurrences 
changes the character of tlie labour completely. Or, she 
may, in consequence of disease or accident, be incapable 
of bringing her child into the light without surgical aid, 
as where the passages are closed by stricture, or by 
some fibrous tumour, or by a deformity of the bones of 
the pelvis. Lastly, the labour may be preternatural be- 
cause there presents at the strait some portion of the child 
which cannot pass through, but must be put aside in 
order to let some other part advance, before the labour 
can be brought to a close. For example, if the arm or 
shoulder should present, it is necessary to put them out 
of the way, and bring the head back to the opening, or 



OF PRETERNATURAL LABOUR. 245 

else the feet must be brought there, and the child turned 
quite over, for one or the other of llie extremities of the 
foetal oval must advance, in order to admit of the escape 
of the child. 

It appears from the above that the causes which con- 
stitute preternatural labour are very various ; and it is 
reasonable to infer that the medical and obstetric treat- 
ment of the several cases will be founded upon the pe- 
culiar and distinguishing character of each individual 
example of the labours. The subject, therefore, em- 
braces so wide a field of discussion and detail, that it 
will be requisite to treat it according to the nature of the 
several causes that happen to interfere with the natural 
process of childbirth, and I shull endeavour to describe the 
different sorts of preternatural labour, according to the 
circumstances which make them what they are, and point 
out the modes of treatment most suitable to their several 
natures. 

It matters not which kind of preternatural labour is 
first treated of, for there is no natural order or method 
of their occurrence; each one might be the subject of a 
separate monograph ; but I have chosen to commence with 
the account of presentations of the shoulder, as one in 
which the operation of turning is inevitable as a part of 
the treatment ; and since that operation is not unfrequently 
resorted to in otlier specimens of preternatural labour, I 
deem it of some advantage to take an early opportunity 
of describing it. 

I have already said that one of the extremities of the 
foetal oval ought to present at the opening, in order to 
constitute a natural labour ; and I have treated of the 
pelvic presentations as being natural ; and I have sup- 
posed that the knee and footling cases are but accidents or 
deviations of the natural pelvic presentation. 

In presentations of the head there is also a liability 
to deviations, by which the head glances off from the 
brim of the pelvis, and is turned upvv'ards into the costa 
of the ilium, or rises above the top of the pubis. 

In a case where the direction of the uterus is very 
oblique, so as to allow the fundus to fall far down into the 
right flank of the patient, the child, if pressed by the 



246 OF PRETERNATURAL LABOUR. 

contractions of the fundus, might be pushed towards the 
left side of the brim of the pelvis in such a manner as 
to make it doubtful whether the head would enter the 
strait, or slide upwards on the left side of the womb. 
For the most part, it fortunately happens, even in the 
very greatest lateral obliquity of the womb, that the head 
is not deflected, but enters the strait; but in a few ex- 
amples it is found to rise upwards, instead of engaging. 
When this takes place, it must almost inevitably happen 
for the shoulder to fall into the cavity from which the 
head was turned away, and as the shoulder is a project- 
ing part, it is very liable to maintain the position in 
which it is once ensconced. The shoulder, therefore, 
when the head glances off, descends or engages in the 
superior strait, and is pushed downwards by the uterine 
contractions as far as it can possibly be urged, and there 
it stops. The strait is jammed full ; and when no addi- 
tional portions of the child can be pressed into it, a total 
arrest of the progress takes place, and the woman, after 
vain struggles, protracted according to the strength of her 
constitution, sinks, at last, without the possibility of res- 
cue from, death except by the skilful aid of the obstetrician. 

There can scarcely be any need for me to enlarge 
upon the impracticability of delivery here except by art ; 
for even could the shoulder be pushed down as low as 
the vulva, it would happen, at last, that the head would 
be again brought to the strait from which it had been 
turned off, but it would be accom.panied by the child's 
body, either of which, alone, is sufficient to fill the exca- 
vation, so that the two together could by no means pass 
through. The remedy is to push the shoulder out of 
the way and to bring the child's feet down so as to de- 
liver it footling, or to restore the liead to its proper place. 

I ought to remark that while the shoulder presentation 
is a deviation or accident occurring in an original head 
presentation, so it may happen that, instead of the 
shoulder, the hand or elbow may come down, but at last 
they are mere circumstances of a shoulder case, and 
when they are advanced to a certain degree, it is the 
shoulder that, after all, fills the strait and the excavation, 
and which constitutes the obstruction. The hand and 



OF PRETERNATURAL LABOUR. 247 

arm are merely prolapsed, and their prolapsion adds 
nothing to the difficulty of the case ; in fact, their prolap- 
sion serves as a means of guiding us in our diagnosis, 
and does not at all oppose the successful treatment of 
the labour. In the management of a pelvic presentation 
I should, in general, prefer that the feet should not 
prolapse ; in a shoulder presentation it would be rather 
a favourable circumstance for the arm to prolapse. 

As there are two shoulders, aright and a left one, there 
must be a set of positions for each shoulder ; but in 
determining which is the position of the shoulder, it is 
also necessary to determine the situation of the child's 
head. In speaking of natural labour, with the vertex in 
the first position, I endeavoured to explain the causes 
which give a greater number of first positions. The 
same reasons operate to produce, in slioulder presenta- 
tions, a greater proportion of instances in which the head 
is to the left side of the pelvis, than of those in which it 
is to the right side. Now if the right shoulder presents 
at the strait, and the head is to the left, tlie face of the 
child, and its toes and feet will look towards the mo- 
ther's back; but if the same shoulderpresents, and the head 
is to the right side of tlie pelvis, the face and front of the 
child must look towards the mother's front: so of the left 
shoulder in the first position, the face will look in front, 
and in the second position it will look towards the 
mother's back. By speaking, therefore, of the positions 
of the two shoulders separately, we get a better and less 
complex idea of this sort of labour than we should have 
were we to enumerate a set of positions without such a 
division. 

I think that the form of the foetus and the capacity of 
the womb are such as to make it unnecessary to es- 
tablish more than two positions for each shoulder, e. g. 
for the right shoulder a first position, or that in which 
the head is to the left, looking backwards, and a second 
in which the head is to the right, and looking front ; 
for the left shoulder a first position, wherein the head is 
to the left, looking front, and a second in which it is to 
the right, looking towards the back of the mother. This 
will, I think, be quite sufficient, and gives us four posi- 



248 OF PRETERNATURAL LABOUR. 

tions for the shoulders, hand or elbow. It is not to be 
denied that the head might be in front, looking to the left 
or looking to the right side of the mother, giving us, in 
the former case, a right shoulder, and in the latter a left 
one in the strait; but it is needless to enumerate such a 
position, as the contractions of the womb would soon 
turn it into one of the attitudes I have before pointed 
out. 

The signs by which a shoulder at the strait may be 
diagnosed, are, 1. The want of the regular form of the 
bag of waters, which in all preternatural presentations 
is without that proper convex shape that we notice in 
favourable instances of natural labour. When the mem- 
branes pass down into the vagina, shaped almost like an 
intestine, or of a cylindrical form, there is good reason 
to think there is something untoward in the posture of 
the infant. 2. The spinous process of the scapula; the 
clavicle ; the round-shaped shouhler ; the axilla ; the ribs ; 
the arm, distinguishable by its size from the thigh. 
Should the attendant retain any doubts, let him never 
omit to remove those doubts by the introduction of his 
hand into the vagina, where he will be able freely to ex- 
amine the nature of the presenting part, and learn its 
true position. No person is excusable for mistaking 
the diagnosis who knows he can command so infallible 
a method of making a correct one. 'J'he diagnosis can 
always be made in good time, — i. e. as soon as the dila- 
tation Will admit, and until then nothing can be done. 

Having ascertained that a shoulder is at the strait, there 
remains but one determination for the practitioner, and 
that is to put it away and bring another part of the child 
to present. This necessity, and the hazard in which, 
consequently, both the mother and child are involved, 
should be plainly and seriously laid before those wlio 
have the best right to know her case ; viz. her husband or 
parents, or such near relatives or friends as may seem 
to be, for the time, in Inco parentis for her. The necessity 
for interference ought also to be explained to the sufferer 
herself, but in the gentlest and most cheering manner 
possible. If it be within the bounds of possibility to do 
so in good time, a medical brother ouglit to be invited, 



OF PRETERNATURAL LABOUR. 249 

in order that his counsel may be taken, and particularly 
that the friends, and the patient also, may have no doubt 
left in their minds as to the propriety of the operation, 
nor claim the least right to find fault afterwards with 
the physician, should any untoward event follow the 
plan he had recommended. 

But no operation can be performed while the os uteri 
is so closed as to refuse admittance to the hand. It 
cannot, and must not, be forced. The mouth of the 
womb must be dilated or dilatable before any operation 
is lawful ; it must be dilated or sufficiently yielding 
to allow the hand to pass upwards into the uterine 
cavity ; of this degree of dilatability the obstetrician 
is the only judge. He must never run the risk of tear- 
ing such an important organ, since its laceration by 
his hand would be much increased by the following 
birth of the child, and place the woman in danger of 
sudden death ; or he might contuse the parts so much as 
to establish a very dangerous inflammation of the organ. 
So important is it to judge aright concerning the time 
to be chosen for the exploration of the womb, that it is 
thought to be the most responsible duty of the physi- 
cian in the whole case. If he proceed too soon, the most 
lamentable consequences are apt to ensue; and if he 
defer the procedure too long, the difficulties and dangers 
are greatly enhanced by the delay, while the patient 
also suffers useless and pernicious pain. The bladder 
and rectum should be evacuated before the operation. 
The position should be carefully ascertained ; this can 
be done by the introduction of the hand, if necessary, 
into the vagina; and if it be certain that the left shoul- 
der presents with the head on the left side of the womb, 
then he must make choice of that hand which can most 
conveniently be employed in the operation. The rule is 
to use that hand whose palm, when opened in the cavity 
of the womb, would look towards the face or breast or 
belly of the child, which, in this instance, would be the 
left hand ; for it is clear that if the right hand were used, 
it would not apply the palm to the front of the infant 
whether it were carried up before or behind the child's 
body. 



250 OF PRETERNATURAL LABOUR. 

The best position for the patient is that on the back, 
with the end of the sacrum brought quite over the edge 
of the bed, the feet and knees being carefully supported 
by an assistant, holding each limb, which should be 
properly flexed. 'J'he woman ought to be carefully 
covered with a sheet or a light blanket, according to the 
season of the year, and some thick cloths should be 
placed on the floor, under the patient, to receive any 
discharges of water or blood that might accompany the 
operation. 

Every thing being fully prepared, the operator's arm 
should be bared up to the elbow, and well anointed with 
lard, while asufficient quantity of the same material should 
be applied to the external parts. During a pain, two 
fingers, and then three, of the left hand, should be passed 
into the vagina, to be followed by the little finger, and 
afterwards by the thumb, strongly flexed into the palm. 
The hand having gained possession of the vagina, may 
then rest while the pain is gone oif, after which the 
presentingpart must be pushed upwards and backwards, 
the fingers and whole hand following the receding shoul- 
'der into the cavity of the womb. The shoulder being 
moved somewhat to the left, as it mounts upwards, when 
the hand is fairly introduced, it ought to be opened and 
glided along the breast or abdomen towards the feet or 
knees, which will be looked for on the right and supe- 
rior portion of the cavity. In searching for the feet, the 
contractions of the womb are excited, and pains are 
produced, especially if the waters are much drained oflf. 
During these contractions it is, absolutely necessary to 
open the hand, lest the uterus, from the violence of its 
own action, might be torn on the knuckles, and the hand 
ought never to move except the organ be in a state of 
relaxation. At length, after more or less research, one 
or both feet, or a knee is found, and whether it be one 
or the other it should be taken hold of; for it is a matter 
of indiff'erence nearly whether it be one foot or both, or 
one knee that is used as the point on which to act in 
turning the child. I say nearly a matter of indiff'erence, 
because, the object being to turn the child as soon as 
practicable, with proper caution, it may be effected in 



OF PRETERNATURAL LABOUR. 251 

either of these ways : it is always desirable to get the 
hand out of the uterus as soon as may be, and it is far 
better to turn by one foot or by a knee, than to incur the 
risk of laceration or contusions of tlie organ, by a te- 
dious search after tlie other foot, w^hich, if it be not ori- 
ginally near its fellow, is very hard to be found by any 
search after it. 

Having found the foot, if a pain comes on immediately, 
and becomes a severe one, the foot should be let go, and 
caught again after the pain is gone off, according to the 
discretion of the operator. During all the time he is 
passing his hand up and exploring for the child, either 
his own hand or that of an assistant should be applied 
to the fundus, in order, by pressing it downwards, to 
keep the os uteri within the strait, and when he is ready 
to turn the child, his own right hand should be used by 
the operator to press on the outside of the abdomen, so 
as to favour the version by pushing the breech of the 
child downwards, while he also draws it downwards by 
the feet or knee. If the hand ought not to move during 
a pain, it would surely be the height of rashness to at- 
tempt to turn the child with the womb in a state of con- 
traction. The time for turning ought to be chosen as 
soon as the pain has gone off. Then the womb feels 
yielding and soft as a wet bladder, and the part held may 
be drawn towards the os uteri slowly and gently, but 
firmly, and, if possible, brought quite into the vagina, or 
even to the vulva. External pressure with the right 
hand favours this version very considerably, and ought 
not to be neglected. 

It is easy to ascertain if the version be complete by 
external taxis, and by noticing how far the child is drawn 
downwards, and judging of its length as compared with 
the length of the uterus, as well as by noting the effect of 
the next pain, which propels it if it be turned, but does 
not move it if it be still transversely fixed in utero. 

Wherever it is possible to make choice of a foot to 
pull on, we should select that which is nearest the front 
of the pelvis. In the present case it would be the right 
foot, because in drawing upon that one, the right hip 
would come under the pubic arch, and favour very de- 



252 OF PRETERNATTRAL LABOUR. 

cidedly our wish to bring the vertex at last to the pubis, 
and carry the face to the hollow of the sacrum : whereas, 
should we draw down the left foot, the child's face would, 
at last, be very sure to come to the pubis. 

As soon as the turning is complete, the case has become 
a footling one, and must be treated as if it were originally 
so ; i. e. it should be left to the expulsive powers alone, 
if they are sufficient, for it is always bad and almost 
always unnecessary to draw out the body ; it should be 
expelled by the pains. The arms must receive such 
assistance as they may need : and the head, being properly 
situated in the vagina, ought to be expelled by the womb 
with such aid, from slight tractions, as the obstetrician 
may adventure with safety to make. 

In going about to perform this operation, the atten- 
dant ought to reflect upon all the dangers incident to it, 
and clearly understand, beforehand, that what is most 
desired in it is, not speed, but safety ; feslina lente 
ought to be the motto. As to the difficulties of it, they 
are so great, in a womb long drained of its waters, and 
lashed into fury by a long period of unavailing irritation, 
suffered previously to the operation, that nothing but 
practical experience of them can make them known, un- 
less indeed the fact be understood that it cannot, in some 
instances, be performed at all, and that we are obliged 
to extract the child double, after having removed the 
thoracic viscera, as well as those of the abdomen, by 
the crotchet and perforator; after which the fcetal remains 
may be drawn forth. 

I have, after having had my hand in the womb, found it 
so completely benumbed by the pressure, as to be unable 
to feel with it or to close it ; in such a case, the other 
ought to be made use of, however ill adapted either for 
the exploration or seizing the feet, &c. 

The child being delivered, the mother must be drawn 
up into her bed, so as to enable her to stretch out her feet, 
and as soon as the placenta is taken away, she should 
be bandaged and put in bed. A grain of opium, or a 
proper dose of laudanum, is very soothing and calming, 
after such high excitement and fatigue, and ought not to 
be withheld from her. A cup of tea or gruel may next 



OF PRETERNATURAL LABOUR. 253 

be presented to her, and a sliort sleep, if she can take 
it, is followed by a comfortable stale, for the before ex- 
hausted woman. 

There is very little difficulty in this operation, if 
the waters are not gone off; they should, therefore, be 
always left whole if possible. Could we indeed always 
have the privilege of rupturing the ovum at the time of 
carrying the h ind into the womb, we should avoid much 
difficulty, and a large moiety of the danger of doing mis- 
chief. 

There are very ignorant persons, who are generally 
the more presumptuous the more they lack knowledge, 
into whose hands women are so unhappy as to fall on 
occasion of tlie childbirth. If, in a shoulder presenta- 
tion, the hand happens to prolapse, they, finding a very 
convenient handle, make use of it to pull the child away 
by ; and 1 have seen a case in which an unfortunate 
woman had been so treated. The arm was wholly 
withdrawn, and the coracoid process of the scapula was 
actually under the pubic arch ; so violent were the 
tractions that had been made on the hand and arm. 
This was done too with a rigid os uteri, which, after 
yielding a reluctant passage for the arm and point of the 
shoulder, was now grasping tlie parts above it with a 
strength like that of a rope, p.nd which afterwards resist- 
ed, for a long time, all attempts to pass the hand along 
betwixt its circle and the child. 

There cannot happen any thing but evil from pulling at 
the hand and arm. Such force cannot pull the child down, 
for it is too large to pass doubled. The hand, actually, 
is not in the way, for the hand of a practitioner and the 
arm of a foetus at term, can never equal in size a circle 
sufficiently large for the head to pass through it. The 
lack of space is not in the faulty construction of the 
pelvis, but in the rigid constriction of the os uteri, which 
if too rigid to admit the hand, is also too rigid to allow* 
the child to escape. That rigidity can be overcome. It 
cannot be needful to excise the arm, or twist it off at 
the shoulder joint, a horrid practice, which seems to 
have received a salutary check from a judicial investiga- 
tion that was had a few years tince in France : a prac- 
w 



254 or PRETERNATURAL LABOUR. 

titioner there, finding it impossible for him to deliver in 
an arm presentation, cut it ofi at the shoulder joint, and 
nevertheless the child was born alive. The obstetrician 
was justly prosecuted on a charge for maiming. 

If the OS uteri will not admit the hand of the accou- 
cheur, it is because it is not dilated or dilatable. Let 
the proper measures, then, for effecting the requisite 
change in the uterine tension be resorted to. They are 
bleeding ; the warm bath ; antimonials; emollient euemala, 
followed by enemata of laudanum ; and patience, though 
last, not the least of the resources for such an occasion. 
Women in labour bear venesection remarkably well ; and 
they demand, in some instances very great abstractions 
of blood in order to get the full benefit of the relaxing 
efficacy of that remedy. A patient bled ad deliquium 
animi, will be more capable of undergoing safely the 
operation of turning, than one left to the unmitigated 
excitement of useless labour pains. 

The warm bath is a safe and an easy remedy for the 
obstinate constriction of the orifice, as it is for all spasms 
and other congenerous disorders. Tartar emetic, in doses 
of the eighth or sixteenth part of a grain, repeated every 
thirty or forty minutes, conduces very powerfully to 
the reduction of the spasm or rigidity, and it may be 
very safely resorted'to in the management of our case. 
Copious enemata of infusion of flaxseed, with a portion 
of castor oil to render it somewhat more aperient, should 
be had recourse to, and they may be followed by anodyne 
enemata, composed of an ounce of flaxseed tea or starch, 
with from fifty to eighty or one hundred drops of lauda- 
num. We should, also, not forget that patience ought 
to work her perfect work, and no more : the accoucheur 
must be the sole judge of how far patience ought to go. 

There can never be the least use in attempting to 
return the arm. The arm will be withdrawn by the 
version of the child. It goes upwards into the womb 
as the head rises, and the breech descends. It would be 
always prudent to secure it by a noose, for the purpose 
of preventing its going too high within the cavity, where 
its presence might cause some embarrassment in the 
delivery of the head. 



OF PRETERNATURAL LABOUR. 255 



Labours are also rendered preternatural by the occur- 
rence of hemorrhage from the womb ; for, although it is 
very common, and not unfavourable for the parturient 
woman to have an issue of blood during some part of the 
process of childbirth, it is not either safe or natural, for 
her to lose so much blood as to give to the flovv the cha- 
racter or title of hemorrhage. In general, the quantity 
lost antecedently to the birth of the child, does not ex- 
ceed an ounce, and it is commonly even less than that. 
The occurrence, therefore, of a show of blood, need not, 
and does not, excite any alarm or even surprise, unless it 
goes beyond the ordinary amount. But where the effu- 
sion becomes excessive, great alarm is felt, and there is 
more or less danger according t^^ the cause of the acci- 
dent. 

I have already indicated my opinion of the mode of 
connexion between the placenta and the womb ; and the 
student will have seen that I do not admit that any very 
large vessels pass from each to the other, interchange- 
ably. Hence, when blood escapes from the uterus, it 
must be, I think, in consequence of an hemorrhagic nisus or 
sanguine determination, like that which sometimes causes 
the effusion of blood from the Schneiderian membrane, 
in those cases of epistaxis that come on spontaneously. 
We often see very copious outpourings of blood in epi- 
staxis, where we can have no reason to suspect any rup- 
ture of vessels or solution of continuity in the membrane. 
The same thing takes place in the pulmonary hemor- 
rhage, and in haematemesis. But as the womb, from its 
very constitution, is prone to the hemorrhagic affection, 
it is more liable than any of the organs, to losses of 
blood, without the suspicion of rupture of its tissues. 

The gravid womb is filled with the ovum, which is 
really connected with the containing organ only at the 
placental superficies. All other points of the ovum, ex- 
cept the placental portion thereof, adhere so slightly as 
to be capable of the easiest detachment. I'he placenta 
itself may commonly be separated with great facility, 



256 OF PRETERNATURAL LABOUR. 

from the surface on which it sits. AVheii the chorion is 
detached from the womb, very little or even no blood 
escapes ; but when the placenta is torn off, the womb gene- 
rally bleeds very freely. Hence, large effusions of blood, 
in labour, indicate that the placental surface of the womb 
is exposed by the separation of the afterbirth from it. 

][ the afterbirth is torn off, or in any manner separat- 
ed from its place, the womb still remaining undimin- 
ished in size, it is evident that the blood may continue 
to flow for an indefinite period, and that the woman may 
be brought into great danger thereby, for the bleeding 
orifices may continue to have, for an indefinite term, the 
same degree of dilatation as that which first caused them 
to bleed. Supposing the superficial content of the gravid 
uterus to be two hundred square inches, and that of the 
non gravid womb to be only three square inches, then, 
it is evident, that the great desideratum in uterine hemor- 
rhages, before delivery, is to empty the organ as soon as 
practicable, in order to reduce its superficial content, as 
nearly as may be, to the smallest number of square inches, 
or to the non gravid state. In treating the cases of alarm- 
ing hemorrhage, therefore, we should ever keep in view 
the fact, that if the womb be allowed to contract, or con- 
dense itself, its own muscular fibres will, by their con- 
traction, lessen the calibre of all the blood vessels that 
are distributed on or in the organ, and in proportion to 
this condensation or contraction, will be the certainty of 
arresting the sanguine effusion. It is not only the orifice 
that is closed, but the whole traclus of the vessel is con- 
stringed. 

If a labour should commence ever so favourably, 
with the child presenting the vertex in the first position, 
and the pains should propel the child downwards, so as 
to give reason to think tlie process about to terminate 
in the most happy manner, yet it might happen that 
hemorrhage should commence, and continue so abun- 
dantly, as to make it absolutely necessary to deliver the 
child, in order to let the womb contract perfccUy. This 
delivery by artificial means converts the labour, which 
commenced naturally, into a preternatural one. We 
should hardly be inclined to call that a preternatural 



OF PRETERNATIRAL LABOUR. 257 

labour, which, though accompanied with a great effusion 
of blood, should terminate well, without any assistance 
on the part of the accoucheur. 

There may also be a very copious and dangerous 
effusion of blood between the birth of the child, and the 
deliveryof the afterbirth; and even when the afterbirth has 
been discharged, the flow of blood may be so considerable 
as to involve the woman in the greatest danger. In the 
management of all these kinds of bleeding, the same in- 
dication is to be kept always in view; to wit, the conden- 
sation or contraction of the womb ; for when that organ is 
truly contracted and condensed, the blood does not flow 
so abundantly as to endanger the patient, except in some 
very rare, and almost unheard of cases. 

But among the causes of uterine hemorrhage, there is 
one which has been called the unavoidable cause, which 
is, perhaps, the most dangerous and difficult to manage : 
I mean that case which depends on the situation of the 
placenta happening to be on the cervix and os uteri. 
This is essentially a hemorrhagic labour, inasmuch as 
the mouth of the womb must not only dilate, but must 
dilate completely, in order to admit of our carrying out 
the great principle, the final condensation of the womb. 
Such an hemorrhage begins very moderately, but as 
larger and larger portions of the placenta continue to be 
detached with every successive dilating pain, it follows 
that the nearer the womb is to its complete dilatation, 
the more profuse and dangerous will be the hemorrhage. 

There are other examples of hemorrhage, in labour, 
that depend on laceration or rupture of the organs, which, 
in common with the other kinds, will now receive a por- 
tion of our attention. 

Every considerable effusion of blood in labour does 
not demand the manual or instrumental assistance of the 
accoucheur. A woman may shed a quart of blood, and 
yet the pains may suffice to expel the fostus in a natural 
way, after which the flow ceases. It is the effect, or the 
probable effect, of the bleeding, that renders it needful to 
interfere, if the pulse begins to grow small and frequent, 
the patient becoming weaker, the countenance paler, and 
the pains less energetic, we have to resolve what course 
w* 



258 OF PRETERNATURAL LABOUR. 

we must take, and then resort to some of the numerous 
expedients for checking ihe discharge. 

If the pulse in uterine hemorrhage be full and throb- 
bing, and the constitution not affected with debility, we 
may, with great safety and propriety, have recourse to a 
bleeding from tlie arm, in order to lessen the momentum 
of the blood, which, by its too great impetuosity, tends to 
keep up the flow and the determination to the womb — 
just as we would bleed in a pleurisy or haemoptoe, with 
a similar view. Such a course, however, would be very 
strongly contra-indicated in the case of a feeble pulse, 
and a general state of weakness, faintness or sinking, 
where there would be no reasonable ground to hope for 
relief by the use of venesection. 

The application of cold to the hypogastric region, is 
often found to have a good effect in checking the san- 
guine effusion, and should be freely resorted to by stup- 
ing the lower belly with napkins, hard wrung out of 
cold vinegar and water ; the application being renewed 
from time to time, until we are satisfied that success is, 
or is not, to crown our efforts. During the employment 
of the above mentioned means, the patient ought to be 
placed in a horizontal posture, with the head very low, 
and the body covered only with sufficient bed clothes to 
keep her comfortable, — the apartment should be freely 
ventilated, and the patient allowed to take any reasonable 
quantity of iced water, or lemonade, while she at the 
same time makes use of the infusum rosae rubrse with 
elixir of vitriol, or the plumbi acetas with opium. 

Such are the general means of repressing the sanguine 
movement towards the womb; but these means do not 
suffice always, and we ought to examine by the touch, 
in order to make sure, if possible, of the cause of the 
hemorrhage. If, upon inserting the finger within the os 
uteri, no portion of the placenta can be felt, and the 
membranes are found to be unbroken, we may perhaps 
resolve to rupture the ovum, with a view to diminish 
the size of the womb by letting its waters run off. If 
a quart of water should escape from the organ imme- 
diately after the breaking of the membranes, the super- 
ficies of the womb, and of course the placental superficies 
would be sensibly lessened, since the organ contracts as 



OF PRLTERNATURAL LABOUR. 259 

soon as the escape of the waters permits it to do so. 
This is the method proposed by Louise Bourgeois, a 
female practitioner in France, many years ago, and it is 
found to answer perfectly well, in many cases. 

There are circumstances, however, that might well 
induce one to defer, to the laiest period the breaking of 
the ovum ; such as a known bad presentation of the child, 
requiring it to be turned. In such a case, no prudent 
person would be willing, without an absolute necessity, 
to permit the water to escape from the womb, previous 
to dilatation, since the operation of turning is vastly more 
difficult, when performed in a female from whom the 
waters have been quite evacuated, than in one in whom 
they are still present. Hence, if the mouth of the womb 
be still very rigid and undilatable, rendering it impossible 
or improper to introduce the hand for turning, any pru- 
dent person would give a very deep consideration to the 
question, whether the membranes ought to be broken or 
not ; and would certainly feel inclined to defer, till it should 
become unavoidable, the rupture of the membranes. 

If, upon rupturing the ovum, the flow of blood should 
not be stayed, and the os uteri should still continue to 
be so rigidly contracted as to make it impossible to 
turn the child, recourse should be had to the ergot, in 
very small doses, with a view of producing a feeble er- 
gotism, or tonic contraction of the womb, not severe 
enough to injure the child, but yet, so strong as to con- 
dense the uterine tissue sutB(;iently to arrest the flow of 
blood from its vessels. With this purpose, five grains 
of the secale cornutum, in powder, ought to be adminis- 
tered every half hour or every hour, according to the 
pressing nature of the demand for its aid ; or a tea spoon- 
ful of the vinous tincture of the same article, might be 
exhibited, at proper intervals, with the same view. 

There is, in general, under these circumstances, a 
strong disposition to make use of mechanical means 
of stopping the hemorrhage, such as the application of 
napkins to the vulva, strongly compressing the orifice ; 
and, also, the plug or tampon, which, filling the vagina, 
is supposed to favour the coagulation of the blood. But, 
if it be remembered that the bleeding orifices are near 
the fundus uteri, and that the extravasated fluid trickles 



260 OF PRETERNATURAL LABOrR. 

down betwixt the chorion and the womb, from the fun- 
dus to the orifice, I think it will be seen that such 
mechanical means can scarcely exert any other than in- 
jurious effects m the case. They may enable us to con- 
ceal the fact, both from the patient and from ourselves, 
that the vital fluid is escaping in a dangerous abundance : 
but common sense ought to show us, that while we may 
prevent the fluid from falling out of the orifice of the 
vagina, by plugging tliat orifice with sponge or other 
materials, we do not prevent it from flowing back upon 
the outer surface of the ovum and the placenta, both of 
which it detaches more and more completely from the 
womb, leaving the woman exposed to greater hazard 
than she would incur were we to permit the blood to 
escape as fast as it is eflfused. Such methods, assuredly, 
will not favour the arrest of the effusion, by coagulation ; 
the source of the flow being too distant from the remedy. 
It-is, in general, better, in uterine hemorrhage, to let all 
the blood that escapes from the vessels, also escape from 
the vagina. When the uterine superficies is diminished, 
the bleeding is stayed. The application of cloths, wrung 
out of iced vinegar and water, to the hypogastrium, is of 
greater avail, and far more safe than the tampon. I 
would gladly urge upon the student the necessity of the 
greatest caution in the employment of so dangerous an 
agent as the tampon, except in the early stages of gesta- 
tion, or where the capacity of the womb is not suffici- 
ently great to admit of its containing a great quantity of 
blood. No hemorrhage is so dangerous as the concealed 
hemorrhage. 

Whenever it is clearly ascertained that the period has 
arrived for the delivery to be hastened, which is known 
by the state of the patient's strength, the pulse, the 
colour of her lips and cheeks, and by the dilatation or 
dilatability of the mouth of the womb, preparation should 
be made for the operation by placing the woman at the foot 
of the bed, as in the case before mentioned. The choice, 
whether it is to be of the hand or the forceps, will turn on 
the degree of advancement of the head, which is readily 
seized by the forceps, if low in the pelvis, but which is 
pushed away to make room for the search after the feet, 
provided it be still within or above the brim of the pelvis. 



OF PRETERNATURAL LABOUR. 261 

In all cases, wherein the vertex is to the left side of the 
antero-posterior diameter of the pelvis, the left hand is to 
be used ; while the right hand is adapted for turning, in 
all examples of labour where the vertex is to the right 
half of the pelvis. The operation ditlers, in no respect, 
from the one already described, except that the head 
must be pushed out of the way, instead of the shoulder. 
If the head should have already occupied the upper 
strait, that strait would be nearly filled with the mass ; 
the hand could not be carried up alongside of it. The 
palm of the hand, therefore, being placed underneath 
the head, would pusii it gently upwards, in the absence 
of pain, and carrying it to one side, it would be retained 
on the brim, by the wrist or arm of the physician, which 
occupies the space recently in possession of the head. 
The exploration or searcli for the feet, would be con- 
ducted as in the case already treated of. 

When I come to speak of the use of the forceps, I 
shall say what is requisite concerning the indications 
and manner of its use in the hemorrhagic aflections ; 
wherefore, it seems by no means needful for me to antici- 
pate here, what I shall feel obliged to say in a future 
page of this book. 



The unfortunate location of the placenta, or the cervix 
and OS uteri, is an accident which does not very frequently 
happen, and which, when it does occur, can scarcely 
ever fail to produce much anxiety and alarm among 
all those who understand the case, and feel any interest 
whatever in the mother and her offspring. The after- 
birth may cover the os uteri so exactly, that the very 
centre of the placenta may correspond to the orifice. 
The danger is enhanced by as much as the location is 
more central, that case being the least dangerous in 
which the edge of the placenta is nearest to the os uteri. 

The occurrence will not be discovered until about the 
seventh month, a term at whicli the cervical portion of 
the womb begins to expand, in order to become a part 
of the general containing cavity for the ovum. As soon 



262 OF PRETERNATURAL LABOUR. 

as (in the seventh month) the cervix begins to stretch, 
parts of the placenta are broken off or detached from the 
surface of the womb, and a flow of blood, more or less 
violent, soon ensues, but which stops as soon as the 
patient lies down, or makes use of a venesection or some 
cooling drinks. The flow having been concluded, it is 
thought to have depended upon sume strain or shock, 
&c. &LQ,., and the patient, having recovered, goes about 
her usual occupations. In a short time, the further ex- 
pansion of the cervix detaches a fresh portion, and the 
exposed womb bleeds again. These attacks of bleeding 
are renewed again aud again, until, by their violence, or 
the weakness they produce, such an alarm is taken, that 
an examination per vaginam is proposed, and acceded 
to, when the cause of so much bleeding is discovered in 
the fact of the unfortunate location of the afterbirth. It 
does not invariably happen that the woman bleeds pre- 
viously to the attack of labour pains, but it is far too 
general an occurrence, not to cause the danger of such 
frequent repetitions to be kept before our eyes, until the 
patient is finally delivered. The loss of blood, by re- 
peated attacks, during the last two months or six weeks 
of gestation, renders the subject of them far less capable of 
bearing the frightful effusion with which she is menaced 
for the day of her parturition ; and one woman who 
might go into labour with a good stock of strength, could 
bear, without injury, a very copious draught on the san- 
guine mass, whilst another one, with vessels already 
drained, should sink, from the further exhaustion of a 
few ounces. 

The presence of the placenta at the os uteri, or pla- 
centa praevia, is denominated the unavoidable hemorrhage. 
The case should be always suspected to exist when preg- 
nant women are attacked with hemorrhage from the 
seventh month to the term ; and the existence of it should 
be verified or disproved by an examination. If it be found 
to exist, then the friends of the patient, but not the patient 
herself, ought to be notified of the nature of her position; 
full instructions ought to be prepared for the manage- 
ment of any future attacks in the physician's absence: 
and the services of another medical practitioner should be 



OF PRETERNATURAL LABOUR. 263 

retained for all sudden emergencies, during the absence 
of the regular allendant. By such attentions as these, 
the patient might confidently expect to secure the ser- 
vices, of at least one medical man, should her own 
regular physician be haply engaged, when her time of. 
suffering arrived. 

When the placenta is prasvia, it will be almost certain 
to produce a bleeding before labour comes on. But that 
bleeding will be far more likely to occur in a woman 
who exposes herself to fatigue and various causes of ex- 
citement, or to accidents, than in a woman who keeps 
jierself quiet, carefully avoiding to make any great ex- 
ertion, or experiencing severe emotions of the mind. 
In all cases of a strong predisposition to bleeding, an 
increased momentum of the blood augments the predis- 
position. Hence, cooling diet, gentle aperients, small 
venesections, and repose, and relaxation from labour, 
ought to be very carefull}'" prescribed for our patient. 
The friends should be enjoined to give us the earliest 
notice of the attack of labour pains, or flooding, so that, 
all preparations being complete, we may have nothing to 
embarrass us in the exercise of our judgment, during the 
actual progress of ihe labour. 

The hazard of perishing, to which the patient is ex- 
posed, depends on the dilatability of the os uteri, and 
the strength of the pains to be employed in dilating it. 
If it be soft, and the pains strong and good, the dilata- 
tion may be completed so rapidly as to prevent the effu- 
sion of any very great quajitity of blood. If, on the 
contrary, it be rigid, and yield very slowly to the feeble 
contractions of the fundus, the loss of blood may be 
very great, and the woman sink before the mouth of the 
womb becomes prepared for the introduction of the 
hand. There is no more important doctrine, in opera- 
tive midwifery, than that which avers that we must never 
presume to force the uterus until dilatation or dilatability 
abstracts from the operation of turning, one of its most 
objectionable characters. 

Dr Collins, in his late work, speaks so sensibly upon 
this subject, that I cannot refrain from quoting the fol- 
lowing passage from page 93 of his book. 



264 OF PRETERNATURAL LABOUR. 

" I know of no circumstance so much to be dreaded, 
as the forcible introduction of the hand where the parts 
are in a rigid or unyielding state; for although turning 
the child is the established and most desirable practice, 
yet the success of this operation will mainly depend on 
the judgment of the practitioner, in selecting the most 
proper and favourable time. Cases will happen where 
he is obliged either to suffer his patient to sink from 
loss of blood, or proceed to deliver when the parts are 
in an undilated and rigid state, in order to afford her the 
only chance of life ; but dire necessity should alone com- 
pel him to hazard the consequences of such violence." 

Such is the language of Dr Collins, who has witness- 
ed a vast number of labours, and whose ample experi- 
ence gives him a tiile to speak as of authority upon this 
and all other subjects connected with midwifery. 

The time for delivery having arrived, the woman, if 
sufficiently strong to bear it, should be brought to the 
edge of the bed, and placed on her back; otherwise, she 
should not be moved, but attended to as she lies. If the 
head present, and the position be unknown, we ought 
to infer that the vertex is to the left acetabulum, which 
is the most comnson one, and of course commence the 
operation with the left hand. By means of the fingers, 
we soon learn which side of the uterus is detached from 
the placenta, and then conduct the fingers in that direc- 
tion, dilating the womb as we proceed, and carrying the 
fingers as far upwards as we conveniently can, betwixt 
the womb and the chorion. The membranes may then 
be ruptured high up in the uterus, and the feet immediate- 
ly sought for ; tlie child should be turned as speedily as 
possible, with proper regard to its safety and that of the 
mother; and the legs, and even the thighs, should be drawn 
into the vagina, not only with the view of expediting 
the delivery, so as to permit the womb to contract, but 
also in order that the thighs or body of the child may, 
by compressing the bleeding parts, arrest or impede the 
flow, and thus save for the patient as many ounces of 
blood as possible. It is to be remembered that it is the 
loss of the last half pint of blood that kills the patient. 
I think that no prudent person would undertake to pierce 



OF PRETERNATURAL LABOUR. 265 

the placenta, in order to get the hand within the womb. 
There never can be so much difhculty in detaching, as 
there would be in piercing the organ : and these two ob- 
jections lie against perforating it, viz. that the rupture 
or laceration of its vessels could not but be destructive 
to the child, which would bleed to death ; and also, that 
if the feet should be dragged through a perforation made 
in the placenta, the final delivery of the body and head 
might be very much retarded, by having that mass to pass 
through, in addition to the other obstacles to the birth ; 
and further, it is evident, that in perforating the placenta 
and extracting the child through its centre, the organ 
could scarcely fail to be very completely detached from the 
womb. It is best, therefore, in all cases, to pass the hand 
betwixt the placenta and the womb, and not through the 
placenta. 

A strong desire to reinforce the tonic contractility of 
the womb would induce me, always, to exhibit a portion 
of the secale cornutum, in these cases, taking care to 
time the dose so as to secure its operation for a period 
posterior to the delivery of the child. The ergot should 
be in readiness, and given as soon as the turning is com- 
pleted. If it should operate successfully upon the uterine 
muscular fibres, it could not but preserve the patient, at 
least, from the danger of a good deal of drainage, if not 
from a more violent and rapid effusion subsequently to 
the delivery. So confident am I in the power of the ergot 
administered in this way, that I venture to recommend 
it very strongly. Many persons, w^ho were constitu- 
tionally prone to hemorrhage after delivery, have escaped 
well, from having taken the spurred rye, in the last mo- 
ments of labour, in order to secure a tonic action of the 
uterus after delivery of the child. 

I need not reiterate my opinion that the operator should 
not be unprovided with the forceps, with which to ex- 
tract the head, in case of any uncommon or dangerous 
delay in its delivery, as I have already stated my opin- 
ion that such means of security ought to be held provi- 
ded for every instance of breech labour, or preternatural 
presentation, of whatever species. 

Fortunately, for us, we do not have to contend with a 

X 



266 OF PRETERNATURAL LABOUR. 

great many cases of placenta praevia. I have seen four 
cases of these accidents, in which the orifice v/as com- 
pletely covered by the afterbirth, and several others in 
which the edge of the placenta was located on the cer- 
vical portion of the womb, and occasioned a certain 
degree of hemorrhage, during the dilatation, but not to 
any dangerous or alarming degree. 

Dr Collins, of Dublin, mentions, that eleven cases 
occurred during his mastership of the lying-in hospital, 
equal to one case in one thousand three hundred and ten 
labours, since he had fourteen thousand four hundred 
and fourteen labours during his mastership. 

It is rather a surprising circumstance that Mauriceau, 
who was so largely engaged in midwifery practice, and 
who witnessed a good many cases of placenta praevia, 
should have been ignorant that the original attachment 
of the afterbirth was on the cervix. This distinguished 
writer always supposed, that when the placenta was 
before the child, it was owing to an accidental detachment 
of it from the fundus, in which it had fallen down to the 
orifice, so as to get in advance of the presenting part ; 
and yet, he very distinctly gives directions how to pass 
the hand, so as in the easiest way to get it by the pla- 
centa, when the operation of turning has to be performed. 



There is another kind of hemorrhage that is met with in 
parturient women ; I mean the concealed hemorrhage. 
It may take place from the placental surface, and con- 
tinue to a dangerous extent, without detaching the cir- 
cumference of the afterbirth from its connexion with the 
womb. In this case, the whole placenta is separated 
from the womb, with exception of its rim ; and the dis- 
tensible material admits of so large a quantity of blood 
being effused, as to make it take the appearance of abag 
filled with blood, and depressed into the uterine cavity. 
I have never met with a sample of this kind of bleeding ; 
but the phenomena that accompany excessive loss of 
blood would give intimation, to an intelligent physician, 
in such a case, sufficiently clear to engage him to pro* 



OF PRETERNATURAL LABOUR. 267 

ceed aright in lessening the bleeding superficies, either 
by merely discharging the liquor aranii, or by turning, 
or delivering with the forceps. The symptoms, under 
such circumstances, would be weakness; dull pain in the 
womb ; suddenly increased size and tension of the organ ; 
frequency and smallness of the pulse ; paleness ; yawn- 
ing and sighing ; and syncope. The occurrence of such 
phenomena, in a pregnant woman, if alarmingly great, 
would be a full warrant for opening the ovum, or for an 
expeditious delivery ; the latter, always, however, to be 
held in reserve until the womb is dilated or dilatable. 
The ergotic action might be, with great prospect of ad- 
vantage, resorted to, in case the hemorrhagic symptoms 
should not abate upon the discharge of the liquor of the 
amnios. 



The hemorrhages that take place between the delivery 
of the child, and the expulsion of the placenta, are fre- 
quently to be met with, and are so violent, as to excite 
great alarm in the patient herself, or her friends who hap- 
pen to witness the distressing symptoms that accompany 
the accident. I think, that, in a very great majority of 
labours, the placenta is quite detached by the time the 
child's head has emerged from the vagina, and the sepa- 
ration frequently takes place still earlier. 

In such women as have feeble pains, with long inter- 
vals, the effusion of blood is very great, and a large 
quantity frequently is found to be expelled immediately 
after the child is born. If this is a correct statement, 
then it may, a fortiori, happen, that the effusion may 
go on rapidly as soon as the body of the child has es- 
caped. The womb, in many instances, is perfectly pas- 
sive, for some time after the great effort it has made, 
and the placental superficies being exposed, a torrent of 
blood issues, which suddenly fills and distends the womb, 
and the woman faints and dies without any one perceiv- 
ing that she has flooded at all. I believe that the blood 
would always flow out of the vagina, were it not that a 
firm clot occasionally happens to stop the os uteri, like a 



268 OF PRETERNATURAL LABOUR. 

tampon, so that none can escape; and if the womb be 
deprived of its irritability, its fibres will offer no resist- 
ance to the fluid which is poured into the cavity, and 
which, being sealed up by a coagulum, must distend more 
and more, and with a rapidity that augments as the pla- 
cental surface grows larger and larger. 

A careful practitioner ought not to allow such an event 
to take place, in his presence. He will frequently place 
his hand upon the hypogastrium of his patient, and ascer- 
tain whether the womb be properly contracted, and en- 
force its contraction, if necessary, by frictions, and by 
gently pressing the womb with his fingers applied to the 
lower part of the abdomen. The irritability of the organ 
is readily excited into effect by this means ; and when the 
womb is properly condensed, there is little danger of any 
effusion taking place. It should be an invariable custom 
to place, after the child is born, the hand on the mother's 
abdomen, to make sure of the contraction of the uterus. 
This custom will give prompt information of the exist- 
ence, or non existence, of a tonic contraction; and he 
who fails of attention to this point will, sooner or later, 
have reason to regret the neglect of so salutary a pre- 
caution. 

But when flooding comes on, whether after delivery 
or antecedently to it, the same principle is applicable, 
viz. to empty the cavity as speedily as possible con- 
sistently with prudence. Let the placenta be taken 
away, and, after its removal, let pressure be made on the 
hypogastrium by the hand, or by a compress, and the 
pressure continued until tjie signs of hemorrhage have 
completely ceased. 



It happens that the womb is incapable, sometimes, of 
separating the placenta wholly from its surface ; but if it 
be half removed, there may flow a great quantity of blood, 
while the uterus continues unable to expel the afterbirth. 
The duty of the medical attendant here is to separate it 
entirely, by introducing his hand, and gently detaching it 
with his fingers, taking every possible care not to leave 



OF PRETERNATURAL LABOUR. 269 

any portion behind, which, by keeping up a continued 
irritation, would tend to maintain a hemorrhagic nisus, 
or even dispose the patient to metritis. 

The greatest care should be taken in this case to keep 
the patient quiet, and strict order should be given not to 
lift her head from the pillows, until all the appearances of 
danger are gone. Any attempt to sit up in bed, or even to 
turn, for a woman excessively reduced by hemorrhage, 
is dangerous, since any muscular effort, by occasioning 
faintness or exhaustion, invites a renewal of the hemor- 
rhage and debility, which are both to be deprecated. 

I have met with several examples of the hour-glass 
contraction of the womb. This depends upon the con- 
traction of the womb at the upper limit of its cervical 
portion, so that the afterbirth is contained, as it were, in 
a separate cell. The finger may pass up to the con- 
stricted point, and find the cord closely embraced by it. 
If no bleeding comes on, it is proper to wait an hour, to 
see whether the co-ordinate action of the muscular fibres 
will not overcome the horizontal constriction ; but, if an 
hour elapses without the least change in the case, we 
have reason to infer that two, or even four hours, may not 
sufiice to remove the difficulty, and we are always jus- 
tified in taking away the secundines in that time, even 
should we not be prompted to do so earlier. It is, in 
general, not difficult to overcome the stricture, by intro- 
ducing, first, the hand into the vagina, and then inserting 
one, then more fingers alongside of the cord, until a suffi- 
cient portion of the hand is introduced to command the 
placenta. 

The application of a compress, made by folding one or 
two napkins, and securing them upon the lower part of 
the abdomen by the common bandage, is a precaution 
that ought never to be overlooked where there is a great 
disposition to hemorrhage. Such a pressure not only 
prevents the womb from filling again, but it tends very 
successfully to secure a firm tonic contraction of the 
organ. 

The sacchar. saturni, combined with opium, in doses 
of three or five grains of the former with from half a 
grain to a grain of the latter, repeated in an hour, ofifers 



270 OF PRETERNATURAL LABOUR. 

US a very useful resource in the styptic influence of the 
acetate of lead. 

Infusion of red rose leaves, with elixir of vitriol ; pow- 
ders composed of five or ten grains of sulphate of alu- 
mine, with a few grains of nutmeg ; and the application 
of cloths pressed out of cold vinegar and water to the 
pubes ; all these are measures that must be sometimes 
resorted to, when the flow of blood continues, after the 
delivery of the secundines has taken place. 



Violent and dangerous efl*usions of blood sometimes 
come on soon after the delivery of the placenta, and at a 
time when the labour is supposed to have been termi- 
nated in the most successful and fortunate manner. If 
half an hour elapses after the delivery of the afterbirth, 
without any flooding, we shall rarely meet with it, and 
may, for the most part, consider the patient safe. Never- 
theless it does, sometimes, come on many hours later ; or 
even many days are passed, without any apparent ten- 
dency to the accident, before the female is attacked. 

The causes of this bleeding are to be sought for in 
the relaxed state of the womb, arising from loss of pow- 
er in its muscular portion. They are almost invariably 
connected with an excited and impetuous circulation, by 
which the blood is propelled with such power and mo- 
mentum into the uterine arteries, as to force their ex- 
tremities, when they are not sufficiently supported and 
constringed by the muscular contractility of the uterus. 

Such an attack ought to be foreseen, and obviated by 
the use of such measures as may serve to abate the vio- 
lence of the blood's motion ; and the patient ought not to 
be abandoned by the physician, until he has become 
fully satisfied that the danger is over. Let the patient 
lie in a horizontal posture ; let blood be taken from the 
arm if required ; let cool drinks be given, and cold water 
applied to the face and forehead ; and let great care be 
taken to ascertain, from time to time, by the touch, exter- 
nally, whether the womb is firmly condensed or not. It 
is not good, I think, to allow the napkins, that are often 



OF PRETERNATURAL LABOUR. 271 

applied to the vulva, to be too firmly pressed to the part ; 
they serve, when so pressed, as a sort of tampon, which 
enforces the coagulation of" the blood in the vagina, and 
that itself is often a dangerous tampon. The blood 
which cannot escape accumulates in the womb, and 
brings on a concealed hemorrhage, that is likely to 
increase with a frightful rapidity that may sink the 
patient irrecoverably by the time it is discovered. 
When blood has once escaped from its vessels, it is of 
no further service in this c&se at least, and therefore 
the sooner it is got rid of, the better for the suflerer. 

Tlie bandage for the abdomen ought never to be omit- 
ted in these cases of flooding, for the belly being sud- 
denly evacuated of the contents of the womb, there is 
produced a feeling of inanition and weakness, that often 
is, alone, able to bring on faintness, or a state approach- 
ing to it; and that is highly conducive to the increase 
of uterine hemorrhage. I have already, in my remarks 
on labours, spoken on this topic, and will refer my 
readers to page 100 and 195 of this volume. 



I have long been impressed with the beautiful simpli- 
city and the truth of the following affecting story, from 
the pen of the celebrated Mauriceau ; and as his writings 
are little known in the United States, I have, on that 
account, as well as for the intrinsic practical importance 
of the case, resolved to translate it for this part of my 
work. Those who read it will, as I think, agree with 
me, that it conveys a most instructive lesson to the 
student of midwifery, and, if I am notmistaken, will need 
no other apology for its introduction here. 



"Many women (says Mauriceau, liv. l,p. 158) have 
perished, together with their offspring, for want of prompt 
assistance on such occasions [hemorrhage] ; and not a 
few have escaped from an otherwise inevitable death 
by early succour ; while their children have received 



272 OF PRETERNATURAL LABOUR. 

the holy sacrament of baptism, of which, but for that aid, 
they would have been deprived. Guillemeau, in his 
liv. 2, chap. 13, De T Accouchement, mentions six or 
seven cases confirmatory of this truth, in most of which 
it is seen that both the motliers and their children were the 
bloody victims of want of promptitude in delivery under 
such circumstances, while some of tliem escaped in con- 
sequence of early assistance : but, that I may confirm 
this doctrine by the results of my own experience, I 
shall relate one case, among many, that is very remark- 
able ; and the remembrance of which is so vividly im- 
pressed upon me, that the very ink with which I now 
am writing, in order to make it known for the benefit of 
the public, seems to me to be turned into blood ; for on 
that piteous and fatal occasion, I witnessed the eflfusion 
of a part of my own vital fluid, or, to speak more cor- 
rectly, the whole of what resembled the blood of my 
own veins. 

" It was sixteen years ago that my sister, who was 
not yet quite twenty-one years of age, about eight months 
and a half gone with her fifth child, being at the time 
in excellent health, was so unfortunate as to hurt her- 
self, though, to all appearance then, very slightly, by a 
fall on her knees, the belly at the time striking the 
ground ; subsequent to which she passed a day or two 
without experiencing any considerable inconvenience, so 
that she neglected to keep herself as quiet as she ought 
to have done ; but on the third day, at about eleven 
o'clock in the morning, she was suddenly seized with 
strong and frequent pains of the belly, which were also 
accompanied by a great discharge of blood from the va- 
gina. She immediately sent for the midwife, who was 
not too well versed in her occupation, and who, when 
she arrived, informed my sister that it was necessary, 
before delivering her, to wait until the pains should 
spontaneously open the mouth of the womb, assuring 
lier, that she had nothing to fear from the accident, and 
would be soon delivered, because the child presented 
very favourably. In this way she fed her with vain 
hopes for three or four hours, until, the flow of blood 
continuing very great, the pains began to leave her, and 



OF PRETERNATURAL LABOUR. 273 

the poor lady fainted away several times ; upon seeing 
which, the midwife requested that a surgeon might be 
sent for to assist her. They came immediately to my 
house, to notify me of the affair; but being unhappily 
from home, they called in one, who, they supposed, was 
one of the ablest obstetricians or surgeons in the whole 
city at that period, and lie was immediately taken to my 
sister's residence, where he arrived about four o'clock 
in the afternoon. Having seen the state she was in, he 
contented himself with merely saying that she was a 
dead ivoman, for whom nothing was wanting but the 
last sacraments of the church ; and that it was absolutely 
impossible to deliver her. To all this the midwife rea- 
dily agreed, for she thought the opinion of this man, so 
universally esteemed, must be, beyond doubt, correct. 
As soon a3 he had pronounced his judgment, he went 
away, refusing to stay any longer ; and in this deplo- 
rable condition, and without offering the smallest suc- 
cour, he left this female, whose life, as well as that of 
her child, he could have certainly saved, had he deliv- 
ered her then, which he might easily have done, as will 
be seen by the sequel of this history. 

" After the judgment of a person of such great repu- 
tation, added to that of the midwife, every one who was 
present tliought that since M. — ; — could do nothing 
for her, there could be no other recourse, in so great a 
misfortune, than placing confidence in God, to whom 
alone every thing is possible. 

'^ They now endeavoured as well as they could, to 
console my poor sister, who with a passionate earnest- 
ness desired to see me, that she might know whether 
I also would pronounce the same judgment upon her; 
and whether her disease, which was constantly growing 
worse, was beyond all remedy; for her blood was stea- 
dily fiov.'ing in great abundance. At last, I returned to 
my house, where tjiey had been a long time before, to 
tell me this bad news; and where, most unfortunately, I 
was not to be found at the time, as I have already rela- 
ted. As soon as I heard of it, I hastened to her house, 
and upon arriving there, I saw so piteous a sj>ectacle, 
that all the passions of my soul were agitated at the 



274 OF PRETERNATURAL LABOUR. 

sight, with many and different emotions : after which, 
having somewhat recovered my composure, I approached 
the bed of my sister, who had just received the last sa- 
craments ; and being there, she implored me again and 
again to assist her, saying, that she had no hope but in 
me. After I had learned from the midwife all that had 
happened, and she had told me of the opinion of the 
surgeon, who had seen her more than two hours before, 
for it was now past six o'clock, 1 perceived that the 
blood still continued to flow profusely, and without 
ceasing, though she had already lost more than three 
parts, and, what is remarkable, more than forty-eight 
ounces within the two hours since the surgeon left her ; 
as I supposed from the quantity of the napkins and 
cloths which were all saturated with it ; which blood, 
by remaining in her body, had she been timeously de- 
livered, would, beyond doubt, have saved her life. I 
also saw that she was seized almost every minute with 
sinking turns, that were increasing ; which convinced 
me that she was in far greater peril than she could have 
been had they not lost the opportunity of delivering her 
two or three hours sooner, w^hich was both possible and 
of easy execution ; for at that time she had almost the 
whole of her strength, which she afterwards lost by the 
continual effusion of her blood. Wishing to know whether 
it was true that she could not be delivered, I found, 
upon examination per vaginam, the orifice of the womb 
dilated, so as easily to admit two or three fingers. 
Having remarked this, I made the midwife examine 
her again, in order to ascertain whether the os uteri had 
been in the same state when the surgeon stated that she 
could not be delivered ; and whether she was still of his 
opinion : she told me " Yes," and that the parts had 
remained unchanged ever since he had gone away. As 
soon as she made this declaration, I perceived her igno- 
rance, and what had been tiie difficulty with the surgeon. 
Touching this, I told her of my astonishment that they 
had both been of such an opinion, as I was of a wholly dif- 
ferent opinion ; for it would have been as easy for him 
to deliver her then, as now ; which, I should, in truth, 
have immediately done myself, could I possibly have 



OF PRETERNATURAL LABOUR. 275 

commanded my judgment, which was long vacillating 
upon the resolution, which, from the loss of all hope 
from other quarters, I was at last constrained to adopt. 
What hindered me was, not the prognostic of the sur- 
geon, celebrated as he was, who had persuaded every 
body that to deliver her was impossible, (for it would 
seem like rashness to resist the dicta of those who are 
looked upon as oracles) nor the weakness of the patient ; 
but it was chiefly the quality of the person, who was 
my own sister, and whom I tenderly loved, that agitat- 
ed my mind with various passions. For, my mind was so 
preoccupied with seeing her ready to expire before my 
eyes, from the prodigious waste of that blood that sprung 
from the same source as my own, as to make it im- 
possible for me to come to an immediate resolution and 
action. This obliged me to send incontinently for the 
surgeon, who had left her so long before, and beg him 
to return to her house, so that I might show him how 
easily she could be delivered, and by making him un- 
derstand and confess that there is no hope on such 
occasions except in prompt delivery, induce him to 
operate, instead of leaving the mother, as he had done, 
to despair, and allowing her infant to perish without 
baptism, which it might have enjoyed had he obeyed 
the requirements of the art, which are, that if both can 
not be saved, we should, at least, try to save the child, 
if that be possible w^ithout doing any thing prejudicial to 
the mother. But he would notcome back for all the prayers 
and solicitations that could be offered ; and excused him- 
self by saying, that it would be impossible to do any 
thing in such a situation. As soon as 1 learned all these 
things, I sent for another surgeon, with whom, had he 
come in time, I should have concluded in favour of the 
necessity of the operation, of the possibility of which I 
could have satisfied him ; but, as misfortune would have 
it, he was absent from heme. Meanwhile, at least an 
hour and a half more elapsed, during which the blood 
was incessantly flowing, and the faintness increased more 
and more. Finding myself, therefore, hopeless of the 
aid of the persons I had sent for, I resolved to deliver 
her myself immediately, for I had not been able to re- 



276 



OF PRETERNATURAL LABOUR. 



solve upon it, except in this extreme necessity, for the 
reasons already given ; which, indeed, was somewhat too 
late for the mother; for had I been able to command my- 
self sufficiently to proceed to the delivery at my first 
arrival, there was great reason to hope for her safety, as 
it afterwards proved as to her child, when I had com- 
pleted the task in the following manner. 

" I introduced two fingers into the orifice of the womb, 
which was open enough to receive them ; I then gradu- 
ally inserted a third, and little by little, the ends of all 
the fingers of my right hand, Vv'ith which I so dilated the 
orifice as to admit the whole handj which is readily to 
be done on such occasions, because, as has been already 
said, the abundant discharge of blood moistens and re- 
laxes the entire womb very much. Having introduced 
my hand very gently, 1 found that the head of the child 
presented, and that the waters were notyetgone ofi', which 
obliged me to break the membranes with my finger nails. 
Having done this, I immediately turned the child so as 
to draw it down by the feet, which I easily eff'ected, as 
I shall describe the operation in the 13th chapter of the 
second book. The operation was efiected in less time 
than it takes to count a hundred, and I protest upon 
my conscience, that I never in my life performed an ac- 
couchement (of a preternatural case) with greater ease and 
expedition, or less pain to the mother, who never com- 
plained in the least during the operation, notwithstanding 
she then was quite herself, and knew perfectly well what 
I was doing. Indeed she found herself quite relieved, 
as soon as I had delivered her, whereupon the flow of 
blood began to cease. 

" As to the child, I delivered it alive, and it was in- 
stantly baptized by a priest vv'ho was in the chamber. 
The patient, and all the bystanders, who were numerous, 
then perceived very clearly that the surgeon and mid- 
wife, who had pronounced it impossible to deliver her, 
had done so without any good reason. 

" The operation was performed in good time to pro- 
cure baptism for the child, who received it, praise be to 
God, as I just now said; but it was too late to save the 
life of its mother, who died an hour after its birth, in 



OF PRETERNATURAL LABOUR. 277 

consequence of having lost too great a quantity of blood, 
for she fell into a great swoon, like those she had had pre- 
viously to the delivery. The flow of blood ceased, it is 
true, but there was not enough left in her body to resist 
these frequent syncopes, which she could doubtless have 
done, had the surgeon who saw her first, delivered her 
three full hours earlier, as he could have done, without 
doubt, as easily as I did it; since which time she had 
lost, without exaggeration, more than eighty ounces 
of blood, twenty of which, had it been reserved, would 
have insured her escape ; particularly, as she was a young 
woman, of a good constitution, free from all disease or 
inconvenience at the time she was attacked by this fatal 
accident, which happened, as before said, at eleven 
o'clock in the morning. She was delivered at seven in 
the evening; but the operation was unsuccessful for her, 
because she had been drained of blood : she died an 
hour afterwards, in full possession of her senses, and 
speaking until the last moment of her existence, which 
was at eight o'clock P. M." 



Among the severe and dangerous disorders to which 
pregnant and parturient women are liable, may be classed 
the puerperal convulsion, as one of the most dreadful. 
It never occurs without carrying dismay among all those 
who take a near interest in the patient; and it exposes her 
to the greatest risk, by the violent aflfections of the brain 
with which it is connected. 

I have already spoken, in a former page, of the excited 
state of the bloodvessels that accompanies labour, and 
I think, that, in view of the rapidity and momentum of 
the circulation produced by the state of labour, no sur- 
prise ought to be felt at the occasional appearance of con- 
vulsions. 

If the extreme violence with which the blood rushes 
along the arteries be taken into consideration, it will be 
seen that the brain must, in such an excited circulation, 
be brought into a state of the highest nervous activity, 
and the function of innervation so considerably augment- 

Y 



278 OF PRETERNATURAL LABOUR. 

ed, in consequence, that the muscles of the body fall 
readily into convulsive movements. The activity of the 
functions of the brain and spinal marrow is always in- 
creased, proportionally, with the quantity of blood circu- 
lating through those structures; a woman, therefore, in 
whom the pulse is uncommonly hard, frequent and large, 
ought, cseteris paribus, to be more obnoxious to the con- 
vulsion than a woman in a directly opposite state. Ac- 
cordingly, I think it will be very rare to meet with the 
malady, except in such as have a very bounding and 
tense pulse. Let it be early obviated. 

The long continued pressure of the womb upon the 
great vessels in the abdomen, cannot fail, in some wo- 
men, to retard, to a certain extent, the flow of the blood 
in the branches of the aorta below the point compressed 
by the womb ; and we daily witness tJie effect of that 
pressure on the veins and absorbents, in the temporary 
varices of the veins, and in the oedematous limbs, of the 
later stages of pregnancy ; which symptoms are observed 
to vanish with the removal of the cause of pressure. 
This removal takes place by the birth of the child, and 
the subsidejice of the womb into the excavation of the 
pelvis, after delivery. The same causes of pressure, by 
impeding, in any degree, the downward flow of the 
aortic blood, must give to the mass of blood a disposi- 
tion to mount upwards, and linger in the vessels of the 
brain and upper parts of the body. They occasion a 
congestion and irritation of the brain, characterized by 
headache, confusion of thought, vertigo and delirium, 
resulting in convulsion or apoplexy. The merest ten- 
dency to such results is worthy of the most solicitous 
regard and anxious attention. Let a pregnant woman 
acquire the habit of congestion in the brain, and if, as soon 
as the efforts of labour come to superadd their power to 
a dangerous predisposition, we omit all regard and care 
for such symptoms, there will be more than a probability 
of our having to contend with tlie disorder now under 
consideration. 

It is far better to ward off than to cure an attack of 
puerperal convulsion. No one can look upon the case, 
with due comprehension of iis nature, and not fear that 



OK PRETERNATURAL LABOUR. 279 

a fatal effasion, or extravasation will take place during 
the attack. It is very well known, that not a few 
instances do occur wherein the fatal blow is struck 
at the very onset, and that some women never speak, and 
never show the smallest sign of reason or sensation from 
the moment of invasion, but sink at once into the ster- 
torous apoplectic sleep, that leads rapidly to the sleep of 
death. 

The state of pregnancy, for some women of a very 
irritable constitution, is rather a pathological than a 
physiological conditon. The woman labours under con- 
stitutional irritation from the commencement of her preg- 
nancy, and never feels well until she is delivered. She 
is fretful and peevish ; ceases to be amiable ; and after 
the conservative powers of the constitution are at last 
defeated and overthrown, the fruits of the disorder are 
seen in puerperal insanity, or convulsions. Such a state 
implies, and maintains a vitiated condition of the circu- 
lation, which should be met by venesections, repeated 
according to the enlightened judgment of the medical at- 
tendant, by purgatives or aperients; by counter-irritants; 
by a judiciously regulated diet; by regulated exercise; by 
proper clothing ; and by the removal or prevention of all 
causes of mental solicitude or excitement. But in order 
to the suitable prescription of all these agents, the phy- 
sician ought to see the patient occasionally, before the 
completion of her term. Hence, the public ought to 
know, that counsel should be taken of the physician, from 
time to time, for all pregnant females who do not enjoy 
good health during gestation. If such counsel were 
sought for at an early period, the attack of convulsion 
would not, in general, take place. Most of the cases 
come on when not in the least expected or anticipated, 
and, as I have already expressed it, " the fatal blow" 
is the first and the last one ; the patient sinks at once 
into coma, and dies, without ever recovering her senses. 

Under the dreadful circumstances of this disorder, 
one reflection ought to strike very obviously the mind 
of the medical attendant; it is, that if the woman were 
not pregnant she would not be assailed by the disease ; 
and the inference very justly follows, viz., the pregnancy 



280 OF PRETERNATURAL LABOUR. 

ought to be terminated in order to put a stop to the 
malady. For M'hether the assault has depended remotely 
on mere pressure on the great vessels, or on that more 
metaphysical state called sympathy of the brain and 
womb, we shall enjoy a far better prospect of rescuing 
the woman if she can be delivered, than we shall if the 
womb remains unemptied. 

But can we deliver? ought we to deliver? and how 
shall we deliver the woman ? We can deliver if the womb 
is dilated or dilatable. We ought to deliver provided we 
find that the discordant operations of the womb are 
likely to fail of bringing the child into the world : for 
although the womb sometimes acts with great power 
during convulsion, and is successfully aided by the vio- 
lent, irregular and spasmodic constriction of the abdominal 
muscles, and other accessories of parturition; it also 
happens, that the child, in some other instances, makes 
no progress at all, and the convulsions return at short in- 
tervals, affording but small prospects of escape for the 
patient, inasmuch as they will be likely to continue until 
the pregnancy is brought to a close by the delivery of 
the entire ovum. 

It is, therefore, always desirable that the patient should 
enjoy the benefits of as early an accouchement as pos- 
sible, but it must never be forgotten that the attempt to 
effect it must be regulated, entirely, by the fitness of the 
parts for the operation. There can be no excuse for 
forcing the hand into an undilatabie os uteri, under any 
circumstances ; and, if the medical attendant be ever 
so anxious to give his patient every possible chance of 
safety, he will not be excusable, if, on that account, he 
rather adds to, than diminishes the risks of her frightful 
disorder. It is true to say that " anceps remedium 
melius quam nullum ;" but let not this trite aphorism 
lead us to the commission of positive mischief, under 
the impression that we are about to employ a doubtful 
remedy. Happily for us, however, delivery is not the 
only recourse to which we can apply in our anxious 
wish to put an end to the danger and distress of the 
scene before us. What are the circumstances of the 
case ? The patient has, perliaps, complained of severe 



OF PRETERNATURAL LABOUR. 281 

pain in the head ; she is under the excitement of labour ; 
she is heated; the pulse is hard, full, and bounding, and 
greatly accelerated. On a sudden, the muscles of the 
whole body become convulsed, and the patient writhes, 
and every feature and every gesture are horribly distorted, 
the respiration is attended with a hissing noise, and 
froth issues from betwixt the teeth, which are firmly 
closed by spasm, giving rise to the peculiar hissing 
sound above mentioned. The eyes are rolled upwards, 
or moved in opposite directions ; and after a greater or 
less duration of the paroxysm, the patient sinks into a 
stertorous sleep, or profound coma, from which she is 
roused only by a renewal of the convulsive movements, 
or to mutter in the intervals, incoherent or inarticulate 
sounds. Here then we have the proofs, as they are the 
results, of a preternatural development of the innervating 
functions of the brain and spinal marrow, which are 
caused by, or maintained by, an undue momentum of the 
cerebral circulation. The remedy is, first, to remove the 
cause by delivery ; and second, to moderate the effect by 
venesection and evacuants. By the abstraction of blood, 
w^e can weaken the force of the whole circulation of the 
blood ; we can make the heart beat gently, and cause it 
to send the blood in a milder current into the vessels 
of the brain ; we can thus diminish the innervative func- 
tion of that organ, and control the muscular excitement, 
wliile, at the same time, we abate the hazard of extra- 
vasations of blood taking place in the substance of the 
brain, or of the eifiision of water into its ventricles. If 
there be a case of disease in which bold and daring em- 
ployment of the lancet is demanded, it is the case of 
the puerperal convulsion. It is scarcely worth while, 
almost, to open a vessel to draw off eight or twelve 
ounces of blood. The patient ought to lose from thirty 
to sixty ounces at one venesection, if possible ; and if 
signs of faintness appear, they should be hailed as the har- 
bingers of success. They will not appear, unless the 
brain is already, in some measure, freed from its state of 
tension ; unless the blood is no longer pushed upon it 
with such force as to excite it beyond measure ; and if 



282 OF PRETERNATURAL LABOITR. 

the mischief at the onset was not too great, there will be 
a greater chance of saving the patient provided they come 
on. 

While we endeavour, by the use of the lancet, to di- 
minish the momentum of the mass of the blood, which 
is propelled in vast quantities upon the brain, we ought 
not to omit the use of other available means of moderat- 
ing the turgescence of the vessels of that important 
organ. The general bleeding should be followed, very 
soon, by the application of cups to the temples and back 
part of the neck, and the hair ought to be cut off, and 
shaved clean, so as to admit of the application of leeches 
to the scalp, and the subsequent use of ablutions of the 
head with iced water and vinegar ; or the use of an epis- 
pastic, with which the cranium should be covered, if the 
coma and other symptoms of local disorder are not in a 
favourable train of abatement. Sinapisms ought to be 
freely applied to the lower extremities, and to the abdo- 
men ; and the location of them should be changed, from 
time to time, so as to keep up a constant irritation of 
some distant part, with a view of diverting the sanguine 
mass from the cerebrum. Enemata of salt and water, or 
of jalap mixed with water, may be made occasionally, as 
a further means of diversion to a safer part of the body. 
During the administration of so energetic an antiphlo- 
gistic treatment, it is in course to observe the most 
rigorous regimen : indeed, until the dangerous symptoms 
are gone off, very little aliment is admissible : solutions 
of gum, portions of barley or rice water, and where 
absolute weakness demands it, sago or arrowroot jel- 
lies, may be given occasionally, yet with great caution. 
Darkness, repose, silence, should all be considered 
essential prescriptions, in a case where so important an 
organ as the brain is concerned, and where the slightest 
irritations are sufficient to turn the scale in an unfavour- 
able manner. 

Long-continued ill health may be, in general, expected 
to follow severe attacks of puerperal convulsions ; and 
nothing but the most constant care and watchfulness can 
avert many evil affections, the sequelae of a state the 
most unnatural and trying to which the female consti- 
tution is obnoxious. 



OF PRETERNATURAL LABOUR. 283 



There are other circumstances that may suffice to 
convert a natural into a preternatural labour. Among 
these may be mentioned the prolapsion of the um- 
bilical cord. The cord very rarely gets down below 
the presenting part of the child, and we have reason to 
be astonished at the rareness of the accident, when we 
consider the great length of that part of the secundines. 
The mere falling of the cord could not, under any cir- 
cumstances, interfere with the ability of the woman to 
deliver herself, because it could not inconveniently oc- 
cupy any space in the pelvis to the hindrance of the 
birth. The importance of the accident is relative only 
to the child, and not to the mother. The child is placed 
in imminent danger of dying by asphyxia, from pressure 
on its umbilical vein and arteries when they fall below 
its head, in labour. Hence, the necessity of expediting 
the delivery by manual or instrumental means, and the 
conversion of the natural into the preternatural kind of 
labour. 

I do not wish to be understood as advising a resort to 
art as an invariable rule of practice in such cases ; for it 
fortunately happens, in some instances, that the pelvis is 
large and roomy, the os uteri dilates rapidly, and the 
pains are sufficiently strong to assure us that the child 
will be born so speedily by the unaided powers of na- 
ture, as to make it unnecessary for us to interfere. The 
child has so good a chance for escaping uninjured, in a 
rapid delivery, that it is more advisable to confide in that 
chance, than to expose the woman and the child both, 
to the hazards of a forced delivery. We also have the 
advantage of being able, by touching the prolapsed cord, 
to ascertain the state of the fcEtus ; if the pulsations con- 
tinue vigorous, we shall suppose the child to be doing 
well, and if they become faint and feeble, we shall be 
able to resort to the forceps or to turning, as the case may 
be. When the prolapsed cord has no pulsation, the 
child is dead, and of course, no steps need be taken 



284 OF PRETERXATL'RAL LABOUR. 

on accoiuit of the prolapsion, which, in that case, 
becomes a matter of indiflerence. 

Many various methods of repositing the cord, or put- 
ting it back into the womb, above the foetal head, have 
been proposed ; they have mostly been found ineffectual, 
the cord being apt to fall down again, even after it had 
been put into the proper place. I have never yet had 
an opportunity to try a method which I beg leave to 
propose to my readers, and which is as follows. Take 
a piece of ribbon or tape, a quarter of an inch wide and 
four or five inches long. Half an inch from the end, 
fold the tape back, and sew the edges so as to make a 
small pocket. Then fold the other end in the opposite 
direction, and sew that also, to make a pocket of it. 
Now if the cord be taken in the tape, and held as in a 
sling, a catheter may be pushed into one of the pockets, 
and that one thrust into the other, so that we shall have 
the cord held as in a sling, which is itself attached to 
the end of the catheter. Let the catheter be now pushed 
up into the womb, beyond the fcEtal head ; it w-ill carry 
the secured portion of cord with it, and the catheter 
being withdrawn, the tape is left in the uterine cavity, 
where no harm can be occasioned by its presence. If 
required, several such tapes could be secured round the 
cord, and all of them fixed on the end of the same ca- 
theter, and pushed at the same moment far up within 
the cavitv of the womb. 



Fainting or syncope, when often repeated in labour, is 
sometimes of so alarming a nature as to induce the prac- 
titioner to be willing to expedite the birth of the ciiild. 
in order to put an end to so threatening a symptom. No 
prudent person, however, would be led to perform so 
serious an operation as turning, or the application of the 
forceps, without being first fully convinced of its neces- 
sity. Of the degree and imminency of the danger here, 
none but a medical person can be supposed a compe- 
tent judge, and the case must be left in his hands, strength- 
ened, as he should be, by the counsels of a professional 



OF PRETERNATURAL LABOUR. 285 

brother. I shall feel satisfied therefore to have merely- 
referred to this cause, and to leave it to the discretion of 
the attendant physician, without any additional remarks. 



A hernia, especially if of a kind liable to strangulation, 
might be a warrant for the accoucheur to hasten the mo- 
ment of relief by the employment of the resources of art. 
We have also, in a few very rare instances, the dread- 
ful accident of laceration of the womb, or vagina, to con- 
tend with. Of course, as soon as either of these acci- 
dents is known to exist, we should resolve to take the 
management of the delivery into our own hands, in 
order that we may, at least, save the infant, while we 
can also offer some faint chances of hope for the safety 
of the patient. 



CHAPTER XVI. 



OF THE FORCEPS. 



In modern times, the resources of the obstetric art have 
been signally augmented by the discovery, and the great 
perfection attained in the construction and use, of instru- 
ments for the forced delivery of the parturient woman. 
Theancients were not wanting in numerous inventions for 
expediting the birth of children, but, unhappily, all their 
instruments were created vvith the sole view and inten- 
tention of being useful to the mother, and had no appli- 
cability to the child, except to extract it after depriving it 
of existence, or even to draw it forth from the womb still 
palpitating with life, and presenting the most shocking 
spectacle of mutilation and distress. The uncus, or 
crotchet, described by Celsus, continued indeed to be 
the model of obstetric instruments down to the close of 
the fifteenth century, when a happy thought resulted 
in the construction of an instrument most perfectly 
adapted to the security of both mother and child, and 
which, at the present day, and in the hands of skilful 
and well instructed persons, may be considered one of 
the greatest trium.phs for suffering humanity. 

Perhaps one of the ideas that would most readily and 
spontaneously present itself, in a case of difficult labour 
with a head presentation, would be, to take hold of the 
head and draw it forth ; and I believe that most of 
the good women wlio so assiduously apply themselves 
to exhort us to help our patients, actually do believe 



OF THE FORCEPS. 287 

that we can take hold of the child's head with our fin- 
gers, and draw it into the world, as readily as we can 
draw a dollar out of our purse, or take an apple from a 
basket. But we cannot take hold of the head and pull 
it down, simply, because we cannot grasp an infant's 
head in tlie hand : we can apply our fingers to one 
side, and a thumb to the other side, and clasp it be- 
tween them ; but, when we attempt to pull the head 
down, we find that our fingers and thumb are not long 
enough to admit of our grasping it ; and we withdraw 
the hand, leaving the head just where it was before we 
made the attempt, and the woman so much the v/orse 
for the additional irritation of her organs. This attempt 
must have been made many thousands of times, and 
always with the same unsuccessful result ; and the idea 
of extracting it with a pincers or forceps sufficiently 
large to grasp the head, must also have presented itself for 
ages ; but how to apply the forceps ? A straight forceps 
could not grasp the head, it would slip off from the head 
as if it was wedge-shaped, while to make the forceps 
curved, so as to grasp the head, would make it impos- 
sible to introduce it, since the forceps must first enter 
into the genital fissure, and then expand sufficiently to 
pass over the parietal protuberances, so as to grasp the 
head when carried upwards far enough. Such, in 
fact, was the forceps of Palfyn, and such must have been 
the instrument spoken of by some Arabians. No for- 
ceps, that could be got on to the undelivered head, had 
been discovered ; and in all cases, where the child could 
not be pushed back and turned, or where the head be- 
came permanently arrested, the medical people were 
obliged, either to let the mother and her offspring perish 
together, or they unscrupulously sacrificed the child, to 
insure the escape of its parent. Our ancestors consoled 
themselves with a quotation from TertuUian, to the fol- 
lowing efiect: " atquin et in ipso adhuc utero, hifans 
inicidaiur necessaria crudelitaie, quum in exilu obli- 
quatus denegat partum^ matricida qui morilurus.'' 
Barely to looit over some of the plates representing the 
obstetric instruments employed previously to the dis- 
covery of tlie modern obstetric forceps, is sufficient to 



288 OF THE FORCEPS. 

produce a shudder, in any one familiar with the difficul- 
ties met with in parturition ; and the griffin's claws, 
sharp crotchets and tire-tetes, which were the boast of 
their inventors, in a barbarous age, serve but to set forth 
more signally, by comparison, the eminent usefulness of 
the modern instrument, to which we are indebted for our 
own escape from the necessity of employing such means 
as were very familiar and commonplace wiih our prede- 
cessors. 

The great desideratum was a forceps that might seize 
the head, and extract it, without inflicting a wound; and 
we are indebted for it to a Doctor Hugh ChamberlaynC; 
who practised midwifery in England towards the close 
of the fifteenth century. He constructed, probably with 
his own hands, two curved pieces of iron, which, being 
introduced separately, M"ere applied in succession to the 
left and right sides of the head, and then united by a 
pivot joint, by means of which the two separate pieces 
were converted into a pincers, or forceps, the handles of 
whicli crossed each other at the pivot or joint, and thus 
became capable of grasping and firmly holding the oval- 
shaped head of the child, while still contained in the 
womb or vagina. As the handles crossed each other, 
and were secured by the pivot, which passed through a 
drilled or mortised hole in the handles, it followed, that, 
when the extremities of the handles were pressed towards 
each other, the head was firmly grasped betwixt the 
blades or clams. The compressing force being duly 
applied, a sufficient degree of extracting power enabled 
the Doctor to draw the head forth from the passages, and 
the child was born without necessarily experiencing the 
smallest injury. 

This great discovery, the essential value of which is 
known only to medical men, would have entitled its author 
to the everlasting gratitude of his fellow creatures, had he 
not tarnished his fame by shamefully making a secret of 
what ought to have been instantly promulgated for the 
general use of all who stood in need of iis merciful inter- 
vention. But the spirit of the age, or a venal spirit of his 
own, induced hmr to confine his secret to his own breast, 
to be communicated, at length, to his two sons, who were 



OF THE FORCEPS. 289 

both instructed in the mode of its use, and are supposed 
to have drawn large profits from the necessities of the 
unfortunate women who, knowing their superior skill, 
were compelled to seek for safety at their hands. 

Little is now known of these persons except their 
names ; and they have deservedly sunk into the oblivion 
which ought to overtake all those, who, whether by acci- 
dent or by the possession of genius, come into the enjoy- 
ment of facilities which ought to be the common property 
of humanity, but who, instead of divulging them and 
spreading their use and employment as far as the want 
of them extends, are induced by a vile thirst for gold to 
retain them within their own hands, and sometimes per- 
mit their secret to perish with them, rather than give it 
all the publicity and currency which its importance en- 
titles it to. Such is the spirit of quackery or empiri- 
cism, under whatever guise, or in whatever art; and the 
fate of the Chamberlaynes, whose memory is almost for- 
gotten already, is but a just retribution for their inhuman 
reservation of their valuable secret. 

There is a very curious and interesting case related 
by Mauriceau,in which he informs us that Chamberlayne 
went to Paris in the year 1609, witli a view to sell his 
secret to the government, and while there boasted, in the 
most confident manner, of his ability to deliver any 
woman, in any labour, no matter how difficult, in half 
a quarter of an hour. It happened, at this time, that a 
woman, with a deformed pelvis, fell into labour, and after 
vain attempts to deliver her, was put into Chamberlayne's 
hands. He undertook the management of the case with 
the utmost boldness, but, after a cruel perseverance of 
two hours, was compelled, through sheer fatigue and ex- 
haustion, to give it over, confessing his inability to effect 
the delivery ; the poor woman perished shortly after 
his retreat, and her body being examined, it was found 
that he had lacerated the womb and vagina in various 
places, with the points of the forceps. Mauriceau was 
so disgusted with the issue of this affair, that he after- 
wards inveterately opposed the use of such instruments ; 
while Chamberlayne immediately returned to England 
z 



290 OF THE FORCEPS. 

and drew very large receipts from the practice of mid- 
wifery in London. 

In 1733, Dr Samuel Chapman published a Treatise 
on the Art of Midwifery, &c., in which the forceps of the 
Chamberlaynes was given to the world, and, from that 
time to the present day, has undergone many modifica- 
tions of form and size, and mode of coaptation ; almost 
every distinguished practitioner, or writer, selecting some 
particular fashion as most in accordance with his especial 
views. 

The instruments first employed, had only one curve, 
that which applied itself to the head of the child in order 
to grasp it; and this was called the Old Curve; so that 
the profile view of it represented a straight instrument. 
Such a straight instrument could be easily applied to the 
head whenever it had descended quite into the excava- 
tion, or whenever the ear could be touched by the point 
of one finger, introduced into the vagina. But in all 
cases, where the head was arrested while in the superior 
strait, a forceps possessing only the old, or original curve, 
could not well be employed in its extraction, because the 
pelvis is itself curved, and hence, when the points of the 
instrument had mounted up sufficiently far to be on a 
level with, or above the plane of the superior strait, the 
handles would necessarily press the edge of the perineum 
back too much towards the point of the coccyx. This 
pressure is both difficult and painful, and endangers an 
early contusion of the perineum or even its laceration. 

Dr Smellie of London, and Dr Levret of Paris, both 
conceived at about the same time, about the year 1743, 
the idea of giving to the blades a new curve on the edges, 
so as to adapt them to the axis of the superior as well 
as to that of the superior strait ; and accordingly they 
produced the forceps with New Curves, which are almost 
universally in use at the present day. Smellie used for 
common purposes his short straight forceps, fearing that 
too general and indiscriminate an employment of the long 
curved one might prove dangerous ; while Levret recom- 
mended his long and powerful instrument as being 
equally adapted for all cases of proper forceps operations. 
Smellie's instrument was united by the reciprocal notch, 



OF THE FORCEPS. 291 

called the English joint or lock, and Levret's was joined 
by a pivot and mortice, with a sliding plate, to secure it 
when united ; both tlie instruments were provided with 
fenestres, but of an insufTicient size to do much more 
than serve to render them lighter. 

The French forceps, somewhat modified by Pean, has 
great vogue in this country at the present time, under 
the denomination of the Baudelocque forceps. It is two 
inches longer than Levret's, and is constructed without 
the bead or raised line that runs round the inner or foetal 
face of the clams, and which was found inconveniently 
to cut or contuse the scalp of the infant. 

This instrument consists of two pieces or branches, a 
right and a left one, intended to be introduced separately 
between the sides of the head and the parts in which it is 
contained; but always so adjusted as to let the concave 
edge of the new curve look towards the front of the pel- 
vis, to suit the curvature of which it was originally con- 
trived or invented. The part that is called the blade or 
clam, ought always, if possible, to be applied on the 
side of the head, and not on the face or vertex, and the 
extremity of the clam should reach up at least as far as 
the chin. Hence, in constructing a forceps, it should be 
always considered necessary to make the clam, or blade 
part, sufficiently long to reach at least from the child's 
vertex to its chin ; a distance of at least five inches in 
the uncompressed state of the head, but which is much 
increased in some cases where the head is subjected to 
severe and long continued compression in the passages. 
But while the head itself requires that the clams of the 
instrument should be five inches long, the different po- 
sitions or situations in which the head is found at the 
time the forceps becomes necessary, demands that there 
should be given to the instrument length enough to em- 
brace the head, whether it be high or low in the pelvis ; 
and that in introducing them, the lock or joint should not 
be carried within the orifice of the vagina. 

There must also be a handle of sufficient length and 
strength to admit of its being used with facility by the 
operator. The forceps therefore is divided into the blade 
or clams, the joint or lock, and the handles. The pro- 



292 OF THE FORCEPS. 

portion of these several parts has been adjusted in various 
ways, according to the taste or judgment of the several 
makers of them. Dr Smellie, who generally employed 
a short straight forceps, constructed them of the length 
of eleven inches, while to his long curved forceps he 
gave a length of twelve and a half inches. 

The French or Baudelocque forceps, in very general 
use in this country, is a very powerful instrument. The 
specimen that I have before me, and which is made by 
Messrs Rorer, is exactly eighteen inches in length, the 
pivot or joint being very nearly midway from the end of 
the clams to the end of the handle. The ends of the 
clams approach within three quarters of an inch when 
the handles are closed or pressed together, while the 
greatest distance between the clams is not quite two 
inches and a half. The blade or clam has an open fe- 
nestre which is not quite an inch wide at its widest part, 
but which is six inches long, growing narrower as it 
approaches the lock, where it is not three-tenths of an 
inch in width. The lock or joint consists of a pivot in 
one branch, and a notch in the other. The pivot is fixed 
into its own blade by a screw, the top of which is a 
thumb piece, by means of which it may be screwed into 
or withdrawn from its place. The notch in the other 
blade is adjusted so as to receive the pivot into the left 
or outer side of the instrument, and the top of the notch, 
being counter-sunk, receives a shoulder at the bottom of 
the thumb piece of the screw, by which means it is made 
perfectly secure against any motion except that of open- 
ing and shutting the instrument. The end of each of 
the handles is curved outwards, so as to make a blunt 
hook, that may, upon occasion, serve all the purposes for 
which the blunt hook is used in midwifery. The weight 
of the specimen is two pounds and seven-eighths of an 
ounce. 

This is a powerfnl instrument, which, in skilful hands, 
may be made use of to overcome very great obstacles ; 
but which, in careless or unskilful application, may be 
the cause of great mischief. It has been objected to by 
many very prudent persons on account of the great w-eight 
of metal, and the severe pressure of the child's head, that 



OF THE FORCEPS. 293 

may, almost unconsciously by the operator, be made 
with it. The late Dr Jaraes very rarely used any other 
than a short-handled straight pair, called Haighton's 
forceps ; yet I have had occasion to witness the appli- 
cation, by him, of a pair modelled upon the plan of the 
Baudelocque forceps. It cannot be doubted that all the 
benefits of the small forceps may be obtained in the use 
of the large ones ; and those who cannot conveniently 
command a variety of instruments, would do well to fa- 
miliarize themselves to that which I have above de- 
scribed. 

The most convenient forceps that I have ever employed, 
and that which I commonly make use of, is the instru- 
ment recommended by Professor Davis, of the University 
of London. 

The instrument nov/ before me is the one described 
in Davis's Operative Midwifery, and was made by Bots- 
chan of London. It weighs ten ounces and three 
quarters, and is in length twelve-inches ; its joint is the 
English joint, composed of a notch in the upper surface 
of the left and in the lower surface of the right branch. 
When the handles are closed, the ends of the clams 
are seven-tenths of an inch apart, while the fenestres, 
at their widest part, are two and three-quarter inches 
asunder. The widest part of the fenestre is equal to two 
inches, and its whole length five inches. From the ex- 
tremities of the handles, to the lock, or point where the 
branches cross, is four and a quarter inches. After the 
branches are crossed they do not divaricate, but proceed 
in parallel lines one inch and a quarter : hence, if a fcetal 
head be ever so considerably elongated by the pressure 
of the parts, the clams are sufficiently capacious to con- 
tain it. In this instrument, such is the width and length 
of the fenestrae, that a large part of the parietal protu- 
berances jut out through them when they are fixed on 
the head. Indeed, the fcetal head, when held within the 
grasp of this instrument, if it be properly adjusted, can 
hardly sustain any injury from it, so admirably is it 
modelled upon the curves of the part. 

I have several times delivered from the superior strait 
with Davis's forceps, an operation for which it is pecu- 



294 OF THE FORCEPS. 

liarly well adapted by the boldness of the new curve, 
particularly upon its convex or inferior edge. I am 
quite free to confess my preference for this over all other 
instruments for the safe delivery of the child, because, as 
I repeat, I think it almost out of the bounds of possibility 
to injure the foetus with it, provided it be perfectly well ad- 
justed, and used with common discretion. I have not ray- 
self employed the German forceps of Siebold, because I 
have considered that the handles are very clumsy, and so 
widely separted, when the instrument is adjusted on the 
head, as to expose us to the hazard of compressing the 
cranium too violently. I have also thought the clams 
too much curved ; but the author of the instrument is 
justly celebrated for his skill, and I am also aware that 
it is the instrument preferred and often used in our city 
by Dr R. M. Huston, whose judgment and skill demand 
my highest respect. This gentleman, who is frequently 
called upon for consultation, has informed me that his 
success with Siebold's forceps causes him to esteem it 
above all others. 



The forceps is intended solely for acting on the head 
of the child, on which it exerts the power both of the 
lever and extractor. When the cranium is firmly grasped 
by it, it may be moved by moving the instrument in the 
direction from handle to handle, or it may be drawn di- 
rectly downwards in the line of motion it would take 
if expelled by the pains. 

In order to get a good idea of the lever-like action of 
the forceps, let the student endeavour to deliver the foetus 
on the machine ; and, for this purpose, let him employ 
a Baudelocque or French forceps. Having grasped the 
head, let him take hold of the blunt hook of the left hand 
branch, and pull by that alone ; and, as he pulls, very 
gently let him move the hook towards the left side, and 
having carried it far enough over in that direction, let 
him take hold of the blunt hook of the right hand branch, 
and pulling gently, or even by merely holding on, enough 
to keep the clam from sinking into the pelvis, if he car- 



OF THE FORCEPS. 295 

ries the handle over to the right side, he wil] find what is 
meant by, and what is the great and efficacious power of 
the lever-like operation of the forceps, when moved, from 
handle to handle. 

The compressive action of the instrument however is 
not needed, further than to cause it to hold the head 
firmly and steadily, while the lever or lateral, or the ex- 
tracting or vertical power is applied through it. It is 
never applied to the pelvis in breech or footling cases ; 
nor can it ever be required in those presentations which 
are manageable by the hand, the noose, or the blunt hook. 

One of the most dangerous errors relative to the for- 
ceps that a student could take up, would be the opinion 
that the forceps is a compressive instrument by its very 
design : it is not so ; it is an extractor ; it is a tire-tete ; 
and I think it ought to be established as a principle in 
obstetrics, that where there is not space enough for the 
descent of the head without the forceps, there cannot be 
produced a due proportion by merely squeezing the head 
down to the required dimensions by such an instrument. 
Lest I might, however, give a wrong impression of my 
views by the above, it is needful that I should state, that 
a head, by long pressure of the pains, may be so moulded 
and reduced in diameter as to be squeezed through a pelvis 
smaller than the head was at the commencement of the 
travail : whenever, therefore, the pains cease, or are in- 
sufficient to reduce it, the forceps, used as an extractor, may 
assist to that end ; they should never squeeze it merely 
to compress and diminish its dimensions ; they should 
always embrace it firmly enough to hold on and draw it 
down, so that the passages may mould it as it descends. 

The celebrated Baudelocque, in order to learn, by in- 
spection, the effects of direct pressure by the forceps, 
procured nine still-born children, and by moulding their 
heads in the hand restored them to the shape of the un- 
compressed head. He also procured three forceps of 
the very best quality, and as nearly alike as possible : 
he then applied the instruments over the parietal protu- 
berances, and squeezed the head until the handles were 
brought into contact, and tied firmly with a string, so 
that the head might be accurately measured while under 



296 OF THE FORCEPS. 

the compression, and then compared with its dimensions 
before the instruments were applied. Such was the 
force employed in bringing the handles into contact, that 
the instruments, though very choice ones, were all 
spoiled by the experiment. The instrument was subse- 
quently applied so as to embrace the forehead and occi- 
put, and the results ascertained. These excellent expe- 
riments, for the particulars of which I must refer the 
student to V Art des Accouchemens, part 4, chap. 1, 
are commented on by Baudelocque as follows : 

"It may be concluded from these experiments : 1st, 
that the reduction in size of the fcetal head, included in 
the clams of tha forceps, differs according to the different 
degrees of firmness of the cranium at birth, and to the 
more or less complete closure of the sutures and fonta- 
nels ; 2d, that this reduction cannot in any case be so 
considerable as has by accoucheurs been supposed, and 
that it can with difficulty, and very rarely, exceed four or 
five lines, with the instrument acting upon the sides of 
the head ; 3d, that the degree of reduction should never 
be estimated from the distance remaining between the 
ends of the handles when they are pressed together in 
the act of delivering the head, nor from the amount of 
force employed to bring them towards each other ; 4th, 
and lastly, that the diameters which cross the compressed 
one, far from increasing in proportion to the diminution 
of the compressed one, do not in general augment to the 
extent of a quarter of a line, and in fact are sometimes 
even lessened." 

The above mentioned results, procured by so distin- 
guished a writer as Baudelocque, ought to suffice for 
removing any lingering disposition we might have to 
regard the forceps as a compressing instrument, and we 
should then be fully on our guard against the propensity 
to use it for such an object; but let it be considered that 
the head does not fill up the pelvis as a nail fills up the 
hole into which it is driven, but that it is always caught 
and arrested by two or perhaps four points on which it 
is impelled, and we shall see that if we do use it to 
squeeze, and reduce the size of the head, we shall only 
reduce those diameters that are already small enough, 



OF THE FORCEPS. 297 

and augment those that are already too large. The most 
proper view to take of the instrument is, that it is a sub- 
stitute for proper labour pain, supplying the want of it 
when wholly absent, or aiding it when its force is insuf- 
ficient to effect the delivery of the woman. Impossi- 
bilities are not to be expected from it ; and in all those 
cases where it is inapplicable, we are compelled to resort 
to other measures of a far less pleasant character. 



It is common to apply the forceps to the head after it 
has got fairly into the excavation, and the nearer the 
head is to the external^ organs, the more easily may the 
instrument be adjusted to it. Hence, whenever, in the 
management of a labour, v^^e begin to perceive the signs 
that indicate the use of instruments, we often feel at lib- 
erty to wait until the presenting part can take an advan- 
tageous position, preferring to lose a little time, for the 
sake of acquiring a greater facility and assurance of safety. 
Whenever the head has sunk so low as to get the vertex 
just under or behind the sub-pubal ligament, we expe- 
rience little difficulty in placing the two branches, suc- 
cessively introduced, into their proper positions, because 
the rotation is completed, and the bi-parietal diameter 
does not occupy the entire transverse dimension of the 
pelvis ; but when we have to apply it before rotation has 
taken place, there is frequently great difficulty in getting 
either the first or the second branch directly over the 
side of the head, but if we fail to adjust the branches 
accurately in opposition, we either cannot make them 
lock, or we lock them in such a way that the edge of 
the instrument contuses or even cuts the part of the 
scalp or cheek on which it rests, leaving a scar, or 
actually breaking the tender bones of the cranium : 
in fact, the forceps is designed for the sides of the 
head ; and if, under the stress of circumstances, we are 
compelled to fix them in any other position, we shall 
always feel reluctant to do so, and look forward with a 
painful anxiety to the birth, in order to learn whether 



298 OF THE FORCEPS. 

we have done the mischief we feared, but which we 
could not avoid. 

I ought also to mention, that cases occur in which the 
forceps is clearly indicated, but in which we can by no 
means apply them ; tire size, and position of the head are 
such that we cannot by force or dexterity get the blade of 
the instrument betwixt the head and the bony passages ; 
in such a case a proper skill and judgment ought to be 
employed, and then, when we cannot succeed, we must 
be content to think that we cannot, and that no one else 
can ; and afterwards, we must resort to other means of 
relief. Further, we can sometimes adjust the forceps per- 
fectly, but cannot effect the delivery, because the parts 
are too small. Here, also, we ought to suffer no feeling 
of mortification to vex us for want of success ; we should 
feel assured that we have exerted a sufficient degree of 
strength and dexterity, a degree equal to what we ought 
to consider safe ; and being then convinced or satisfied that 
our duty has been, in so far, done, we lay aside the for- 
ceps to resort to ulterior measures. 

I have already said that the instrument is made for 
the head, to which alone it can be safely applied. It 
would crush or cut the breech, and the sides or the belly, 
if applied in breech presentations to those parts. 

It cannot be applied unless the parts are favourably 
disposed ; for instance, the os uteri must be dilated some- 
what, and also dilatable. The vagina and perineum also 
must be in such a condition that we need have no fear 
of lacerating any of those parts, or the operation is con- 
tra-indicated. 

The pains must have been proved insufficient for their 
office. We should find ourselves inexcusable, if wes hould 
be led to use them where the pains are still of vast force, 
and where they fail of success on account of a preter- 
natural resistance. If we judge that the power of the 
pains is already as great as the patient ought to bear, 
we ought not to apply the forceps, in order to add to 
the forces, which are already perhaps, of a dangerous 
degree of intensity. 

The motive for the use of the operation should be 
clearly understood, as referring both to the mother and 



OF THE FORCEPS. 299 

child ; to the mother alone ; or to the child alone. The 
consent of the responsible and interested persons should 
be obtained ; and, if time permits, some professional 
friend should be invited to witness and sanction the ope- 
ration. 

The position of the presentation should be well known ; 
and, if needful, by the introduction of the hand into the 
passage. The bladder and rectum should be evacuated, 
the former by an enema, and the latter by the catheter ; 
the last precaution ought never to be neglected. 

The bed should be prepared by briuging the end or 
side of it quite to the end or side of the bedstead, and 
then covering it with blankets and sheets of sufficient 
thickness to prevent the bed from being soiled. Part of 
a sheet should reach down to the floor, on which some 
cloths ought to be placed, to receive the fluids that com- 
monly escape during the process of delivery. 

The patient ought to be brought to the side or end of 
the bed, as the case may be, lying on her back, with the 
end of the sacrum projecting far enough over the bed to 
admit of the most unrestrained access to the parts by the 
hand and the forceps. While lying in this manner the 
feet should rest on two chairs or on the laps of her as- 
sistants, sitting with their backs turned to the patient, 
and far enough from each other to allow the operator to 
stand between them. 

The instruments, at all seasons of the year, should be 
placed in a bowl of tepid water ; and, when ready, they 
should be anointed with sweet oil, which adheres to 
them better than lard. 

Lastly, the parts should be freely anointed with lard, 
the patient being always carefully protected from expo- 
sure by a sheet thrown over her. 



The forceps are differently applied, according as the 
head is diflerently placed. 

If the vertex present, and rotation have taken place so 
as to bring the point of the head just below or behind 
the sub-pubal ligament, the left hand blade is to be taken 



300 OF THE FORCEPS. 

in the left hand, and the fore and middle finger of the 
right hand should be passed upwards as far as conve- 
niently can be done betwixt the left ischium and the 
child's head, somewhat towards the posterior part of the 
pelvis, or towards the left sacro-iliac junction. The 
branch should be so held as to cross the right groin, in a 
direction from above, downwards and inwards, so as to 
let the point of the blade be near the vulva, into which, 
it is, next, gently and slowly introduced, allowing the 
concavity of the old curve to be in contact with the con- 
vexity of the head. In proportion as it immerges, the 
point is directed upwards, towards the plane of the supe- 
rior strait, the handle coming downwards as the intro- 
duction proceeds, and care being taken to direct the point 
by the two fingers as far as they can reach. If any ob- 
struction or difficulty is met with, let it be overcome by 
gentleness and dexterity, and not by force. For example, 
if the point comes in contact with the ear, that organ 
might very easily be lacerated by any rude force, and a 
great deal of caution ought to be observed in order to 
protect the child from such a maiming, and the medical 
attendant from such a disgrace. At length the blade is 
introduced sufficiently far to show that the point is nearly 
even with the chin, and the old curve in contact with 
the side of the cranium and face, and that it covers the 
ear. 

The end of the handle should now be depressed a 
little, and given in charge to one of the assistants, while 
the right hand branch is taken in the right hand, and the 
fore and middle fingers of the left hand are introduced 
into the vagina, as in the case just described. The branch 
is laid across the left groin, looking from above down- 
wards and inwards, and the point of the blade is passed 
into the vagina above the first branch. This one should 
also be at first directed towards the sacro-iliac junction 
of the right side, and elevated as it proceeds so as to be 
brought at last into exact opposition to the left hand 
branch. If any difficulty occurs in getting it forwards 
enough, the two left hand fingers that are guiding it will 
serve to slide it edgeways into the proper position. The 
branches are now to be joined at the lock ; and the union 



OF THE FORCEPS. 301 

of the branches is very easily to be eflected if the oppo- 
sition of the two counterparts is accurate. When locked, 
let the handles be brought near enough together to show 
that the head is firmly grasped, and then the instrument 
is to be withdrawn a little, in order to effect its complete 
adaptation to the convex surface which it liolds or con- 
tains, within its jaws. If the handles come into con- 
tact with each other, the head is not held properly ; if 
they gape wide apart, the clams are not upon the parietal 
protuberances: they ought to be about an inch apart. 

Whenever, during the introduction, a pain comes on, 
the attempt should be suspended until the pain goes off, 
and then resumed, lest the os uteri might suffer a con- 
tusion or even a laceration by llie iron. 

The handles will point downwards towards the wo- 
man's feet, according to the degree of advance of the 
head, or they will point more upwards : their direction 
ought to be nearly parallel to the occipjto-mental diam- 
eter of the infant's head ; or the lines should divaricate 
not more than from five to ten degrees, according to the 
boldness of the new curves of the forceps employed in 
the operation. 



The instrument is now adjusted ; let care be taken that 
no external part be caught or pinched by the lock or 
joint. This is ascertained by passing the fingers round 
and within the orifice of the vulva. In general, no at- 
tempt to extract should be made until pain or tenesmus 
come on. When the woman is ready, therefore, let the 
handles be held in the left hand, while the middle finger 
of the right hand is placed in front of the joint or cross- 
ings, to assist in the extraction, while the index finger is 
to be pressed against the child's head, and always retained 
in contact therewith, during the extractive eli'ort. The 
finger ought always, in this stale, to reach the head; but 
if it leaves it, it is because the blades are slipping off, in 
which case traction should cease until they are adjusted 
again. While the finger remains in contact with the 
head, there is no slipping of the instrument. 
2 a 



302 OF THE FORCEPS. 

The most successful mode of using the instrument at 
first, is to employ it as a lever, by moving it from handle 
to handle, exerting at the same time enough extractive 
force to prevent the opposite blade from plunging deeper 
into the parts, while we move the handles to the right, or 
to the left. 

In exhibiting to my class a demonstration of the lever- 
like action of the forceps, after having adjusted the instru- 
ments on the head, in the phantome, I take hold of the 
blunt hook of the left hand branch, and leaving the other 
untouched, I draw that branch a little out, and at the 
same time carry it over towards the left thigh ; in this ac- 
tion the blade of the right hand branch is found to be with- 
drawn considerably, bringing the head along with it. I 
next take hold of the blunt hook of the right branch, and 
drawing a little downwards, I carry it over towards the 
right thigh of the phantome, by which the blade of the left 
branch is withdrawn in like degree, bringing the head, 
which it grasps, along with it; so that by several succes- 
sive movements of the sort the head is soon found to 
emerge completely from the vagina. One trial of this 
metliod on the phantome, will show the student how pow- 
erful is the action of the forceps used in this way. 

In practice, all attempts at extraction ought to be made 
in conformity with the natural processes and disposi- 
tions or tendencies of the healthiest labour ; there ought 
to be no hurry, no impatience, no temper exhibited by 
the operator. 

In natural labour there are intervals of rest ; in artifi- 
cial labour there ought also to be good intervals of rest ; 
which are required both for the physical relief, and the 
moral relief of the patient. Her mind is strained to the 
higliest tension, by the mere thought that she is under the 
operation, and the tissues against which we are dragging 
tlie child, yield better,for a minute or two of rest, repeated 
from time to time, as the case admits or demands. 

It should not be forgotten that the forceps embrace the 
head in a direction from the vertex to the chin; nor that, 
when the head is evolved under the stress of the instru- 
ment, it ought to undergo the same mutations as it 
would if expelled by the natural pains. Hence, as the 



OF THE FORCEPS. 303 

vertex emerges, and rises towards the front of the pubis, 
the ends of the handles rise along with it. In the 
last moments of the delivery of the head, during its ex- 
tension, the inferior part of the occipital bone rests in 
contact with the raons veneris. If the forceps are still 
upon the head, in this situation, their handles will tend 
towards the abdomen of the mother, or they will at least 
acquire a perpendicular direction, if she lies on the back. 

A goodly proportion of the examples of forceps ope- 
rations met with here, are, as I think, rendered necessary 
by rigidity of the soft parts, to overcome which, the expul- 
sive faculties have been exhausted by vain efforts. Let 
it be well borne in mind that the expulsive powers of 
the womb are enormously great, and that they some- 
times fail of success because the vagina is not dilatable, 
or the perineum will not yield, or the labia will not suf- 
fer elongation, or all these obstacles may be in combined 
opposition to the delivery : remembering these things, 
w^e should not impatiently urge nature beyond her powers, 
lest we do injury where we are most solicitously en- 
deavouring to do good. By rude and untemporizing 
exercise of strength, we incur very great hazard of rup- 
turing these organs, and of bringing ourselves into some 
discredit, and of maiming the patient most injuriously. 
It is very true that the forceps acts as a dilator by sepa- 
rating the sides of the vagina and of the vulva before 
the advancing head ; but, on this very account, and 
because it is so powerful a dilator, we are bound to 
exercise the greatest prudence in the use of it. I 
have, in many instances, refrained from the use of the 
forceps, in cases where they were, on other grounds, 
strongly indicated, because I could appreciate the im- 
practicableness of any attempt suddenly to dilate the 
external organs, which I perceived to be far more fran- 
gible than dilatable. 

It not unfrequently happens, that, in cases where the 
head has suffered a long arrest, and the natural powers 
have proved incompetent to its effectual advancement, 
the application of the forceps, and very moderate trac- 
tions with the instrument, will put it in rapid motion, so 
as to leave no doubt of its speedy expulsion under the 



304 



OF THE FORCEPS. 



natural powers. In such cases I have been accustomed 
to remove the forceps, and allow the child to be born 
by the spontaneous exertions of the womb. I do 
this with the view of sparing pain to the mother, and 
under the conviction that the oraans are less likely to 
suffer contusion, or laceration without, than w^th, the in- 
strument. But it ought not to be done except under full 
conviction that the expulsive powers will be successful, 
since it is very mortifying to withdraw them unnecessa- 
rily, and be obliged to reapply them. 

Inasmuch as we cannot exert any very considerable trac- 
tile force, without compressing the head wdth a severity 
proportioned to it, we should occasionally relax our hold 
on the handles, in order to let the blades cease from 
pressing the cranium. The effects of the pressure are 
rendered less dangerous for the child, by being occa- 
sionally intermitted. The same reasons are conclusive 
against the practice used by some persons, of tying the 
handles with a fillet, which makes it impossible to relax 
the grasp of the clams, without the trouble of untying 
the fillet, every time such relaxation happens to be 
thought of. 

Extreme caution is required for conducting the last 
stages of the operation with safety. The perineum 
should be well supported with a napkin held by the 
operator, or an assistant ; and the delivery of the head 
should be deliberate and slow, and the patient exhorted 
to lie as still as possible. In delivering a lady rather 
advanced in life, of her first child, I was using a mode- 
rately strong traction while the head was passing out. 
On a sudden she threw up the pelvis, which changed 
the line of movement of the head, as I had the han- 
dles of the forceps pretty firmly grasped during the mus- 
cular efforts I was making; I could not let go soon 
enough to prevent the head from lacerating the perineuni 
very severely. I felt then, and still do feel confident, that 
the perineum would not have been torn but for the very 
unexpected and violent movement of her pelvis. She 
recovered from the effects of the laceration in about 
three weeks. 

As soon as the head is delivered, the forceps are to be 



OF THE FORCEPS. 305 

removed and handed to an assistant, while we take care 
to attend to the delivery of the shoulders, and finally, re- 
ceive the child, which is to be done as in the most 
natural labour. 



A more difficult operation than that just described is 
the application of the forceps where rotation of the head 
has not taken place. 

The first, and one of the most important steps here, is, 
to ascertain accurately, I say with absolute accuracy, the 
situation of the foetal head. If the finger can reach the 
posterior fontanel, we ought to be able to appreciate, 
from that point, the relative situation of all the other parts 
of the head. If any doubt however remains upon the 
mind, after an attempt to discover the truth by the em- 
ployment of the finger alone, the whole, or one half of 
the hand should be introduced into the vagina, so that by 
grasping the cranium with several fingers, we may become 
positively sure that our diagnosis of the position is correct. 
We will suppose the examination to have resulted in 
ascertaining that the vertex is in the first position, i. e. di- 
rected to the left-and-front side of the pelvis. 

The patient is to be placed upon the back, as in the 
other case, and the left hand branch of the forceps, gui- 
ded by two fingers of the right hand placed in the left 
posterior part of the vagina, is to be passed upwards in 
front of the left sacro-iliac symphysis. The end of the 
blade being conducted up to the child's chin, it will be 
found that the pivot of the blade will look upwards and 
to the left, and the handle will be inclined towards the 
left thigh of the patient. The blade being properly ad- 
justed, an assistant should be put in charge of the instru- 
ment, while the right hand branch, guided by two fingers 
of the left hand, is next to be introduced into the right 
and lower part of the vagina, and gradually conducted 
forwards along the side of the head, to the right side of 
the chin, so as to cover the ear; the notch being just op- 
posite to the pivot. If the blades should not be found 
opposite to each other, they will not lock; they must be 
2 a* 



306 OF THE FORCEPS. 

placed in opposition by bringing one of them more to the 
front of the pelvis, or pushing the other more towards 
the sacrum, and when they pressupon the opposite sides 
of the head, there is no difficulty in uniting them. AVhen 
the branches are locked, they are inclined towards the 
left thigh of the mother, the pivot still looking upwards 
and to the left, and the handles having an appearance of 
awkwardness in this situation, which, to a tyro, commu- 
nicates a feeling of doubt as to their being well placed. 
They look as if tliey were crooked, but this very awk- 
wardness is the best evidence of their being situated right. 
When ready to proceed with tiie extraction, advan- 
tage should be taken of the first pain, not to rotate the 
head by twisting the vertex to the right, but by moving 
the instrument from handle to handle, using at the same 
time a proper degree of traction. The rotation takes 
place as the head advances, and the vertex very soon 
comes under the pubic arch, without any particular ef- 
fort being made to rotate it. As soon as the vertex 
reaches the pubis, the peculiarities of this application of 
the forceps cease, and the remaining steps of the opera- 
tion proceed as in the first describee! case. 



The vertex may present in the second position; in 
which case the posterior fontanel is towards the right 
and front of the pelvis. Let the woman be placed as 
before ; and after introducing two fingers of the right hand 
into the left side of the vagina, the left hand branch of 
the forceps is to be conducted into it towards tlie four- 
chette, the point of tlie blade sweeping upwards towards 
the child's chin, covering part of the ear, and coming 
off at the vertex. The handle will look towards the 
risrht thigh, and the pivot will ])oint upwards, and to- 
wards the right. The handle of the forceps should be 
very much depressed in this case, because as the lock 
portion of the branch is inclined towards the right, it 
leaves scarcely space for the introduction of the female 
counterpart, which is to be introduced on that side ; but 
a considerable depression of the handle affords a more 




307 



OF THE FORCEPS. 307 

abundant space for that purpose. The branch, being 
correctly placed, is put in cliarge of an assistant, while 
the right hand blade, being guarded by the introduction 
of two fingers, is passed into the vulva at its lower or 
back part, and its point turned upwards and towards the 
left, as the handle sweeps downwards and towards the 
right. 'I'he joint is brought into apposition and locked. 
As soon as a pain comes on, traction, combined with 
the lever-like action, must be instituted, and as the head 
descends, the mechanism of the pelvis compels the ver- 
tex to rotate towards the pubis, under the arch of which 
it soon begins to jut. This being effected, the peculiari- 
ties of the operation are removed, and its remaining 
conduct is to be fulfilled as before. 



In those cases in which the vertex, instead of coming 
to the arch, rotates backwards and falls into the hollow 
of the sacrum, the forceps will be more likely to be re- 
quired, because the difficulties of expulsion are greatly 
enhanced by the position. In this, as in all the occipito- 
anterior positions, the vertex must escape first ; but in 
order to do so, it must glide down the sacrum and coccyx, 
and along the perineum, after having distended it enor- 
mously, until the fourchetle slides backwards and up- 
wards beiiind the occipital bone of the infant. In order 
to effect this, the occipito-rnental diameter of the foetus 
must become j)arallel with the axis of the inferior strait, 
or at least it must become nearly so. Such, however, is 
the exceedingly violent flexion required for that purpose, 
that much time is lost before it can be effected; and the 
woman is, in many of the instances, exhausted, and the 
pains gone, before it can be completed. 

The position is ascertained by feeling the large fonta- 
nel behind the pubis, or just wilhin the arch, while the 
sagittal suture runs backwards towards the sacrum. 

When it is found that the forceps will be required to 
extract the head, let the male branch, held in the left 
hand, be introduced into the back part of the vagina, and 
conducted towards the chin as far as possible, carrying 



308 OF THE FORCEPS. 

the instrument up near the left sacro-iliac junction at first, 
and gradually bringing it forwards so as to apply it ac- 
curately to the side of the head. The oblique diameter 
of the head dips so much towards the sacrum, that it is 
impossible to embrace the head properly without de- 
pressing the handle very much, and tiirusting the edge 
of the perineum very far back, which, though not a little 
painful, cannot be avoided. The instrument being held 
in this way by an assistant, leaves a sufficient space on 
the right side of the vagina for the introduction of the 
female branch, which being adjusted and locked in the 
male branch, leaves the handles very much depressed. 

Having been well satisfied that none of the external 
parts are pinched at the lock, and that the head is firmly 
grasped, the first movement in extraction should be to 
raise the handles up a little, with a view to compel the 
chin to approach still nearer the breast, and in that way 
permit the vertex to glide down the sacrum and coccyx, 
assisting its descent by means of the lateral or lever 
action of the forceps. 

As the perineum must, in this labour, be enormously 
distended, it behoves that great care and patience should 
be exercised, lest it might give way. It should be well 
supported, and as soon as the vertex clears the edge of the 
perineum, the handles ought no more to be raised, but on 
the contrary depressed, in order to let the head extend 
backwards — a movement exacdy the reverse of what 
takes place in the Occipito-anterior position. The head 
being delivered, the shoulders rotate in the excavation, 
and the right or the left one comes to the pubic arch, so 
that the rest of the process is concluded as in a first or 
second position. 



The application of the forceps for the occipito-posle- 
rior positions, say the fourth or fifth, where rotation has 
not taken place, is more difficult than the one just above 
treated of. The blades are with nmch less facility ap- 
plied, and indeed cannot take hold along the oblique 
diameter so completely as is to be desired ; they rather 



OF THE FORCEPS. 309 

seize the head alonjr its vertical diameter at first, and are 
gradually brought into parnilelism with ihe oblique one, 
as extraction proceeds. Reflection upf)n this circum- 
stance is very needful, at the time of ihe operation, lest 
the infant's head be, by want thereof, contused and even 
cut by the blades. 

The introduction takes place as in a first or second 
position, the fourth corresponding to the first, and the 
fiflli to the second. Tiie handles must be well de- 
pressed in this case, and it will be allowable to make 
prudent efforts to rotate the vertex into the hollow of the 
sacrum — it being always understood, that in such iabonrs, 
all hope of bringing it to the pubis, hath, after experi- 
ment, failed. 



The head is sometimes situated transversely, the ver- 
tex resting against one, and the foroiiead against the other 
ischium. Let us suppose the vertex at the right ischium. 
It is intended to apply the male blade to the left side of 
the head, wit?i the concave edge of the new curve look- 
ing towards Uie occiput. 

Let the left hand branch be therefore introduced into 
the left and posterior part of the vagina, and as the point 
enters more and more, the handle should be depressed, 
until the curve applies itself on the left side of the head 
in a direction from the vertex to the chin, or as nearly 
so as may be practicable. It should be understood, 
however, that the blade will scarcely apply itself in that 
direction, because the chin is not so near to the breast 
as it ought to be. When the blade is adjusted, its pivot 
looks to the right, and lies in a horizontal position, while 
the handle juts out very obliquely towards the right 
thigh, which is much abducted. 

As the left hand branch projects towards the right, 
there will be some difiiculiy in finding room for the in- 
troduction of the right hand branch ; yet the other can 
be temporarily pushed out of the way, so as to let the 
point enter at the inferior and right side of the orifice of 
{he vagina. When the curve is applied to the convexity 



310 OF THE FORCEPS. 

of the cranium, it must be puslied upwards, backvvards 
and towards the left, so that its point may approach the 
chin, and the notch be brought in apposition with the 
pivot, and so locked. The head bein^ firmly held, 
may be moved in the direction from handle to handle, 
and moderately rotated, so as to dislodge it ; and the 
tractions being soon commenced, it is found to descend, 
the forceps rotating along with it, until tlie pivot turning 
to the left becomes vertical, and the fontanel appears at 
the arch. 



Now it appears, that in all the operations I have de- 
scribed, the male or inferior blade is to be first introduced, 
without doing which, the female or upper blade cannot 
be introduced, without getting it below the inferior blade. 
There is one position of the head, however, in which it 
is proper to introduce the female blade first — and there is 
but one — which I shall proceed to treat of. The position 
to which I allude is that in which the vertex touches the 
left ischium, and the forehead the right ischium. 

It is clear that when the instrument has grasped the 
head in this position, the handles will project very much 
towards the left thigh, in abduction ; but if we introduce 
the male blade first, inasmuch as its handle will project 
towards the left thigii, it will occupy all the space on 
that side, and hinder or prevent the insertion of the se- 
cond branch, for there is no place for the handle to be de- 
pressed in. To avoid this difficulty, therefore, take the 
female or upper blade in the right hand, and introduce it 
into the posterior and right side of the vagina, conducting 
its point as near as may be to the chin, and over the 
face to the right side of the head behind the pubis, leav- 
ing the handle to project towards the left thigh. Next 
take the male blade into the right hand, and turning the 
concave edge of the new curve downwards, insert the 
point into the right side of the vagina, below the female 
branch. Let the fceial face of the clam apply itself to 
the convexity of the head, and slide it onwards, and in 
proportion as it enters, make it sweep round the crown 



OF THE FORCEPS. 311 

of the head towards the back of the pelvis. In effecting 
this, the handle comes gradually down as the clam gets 
on the left side of the cranium, and at last the lock is 
found to be where it ought to be, viz. under the upper 
or female blade, with whicli it is then locked. 

When we have ascertained that the head is properlj'- 
held, or grasped, we may proceed as before, to move and 
to attempt to rotate it, and then deliver as soon as the 
vertex emerges from beneath the symphysis pubis. 



Among sixteen thousand four hundred and fourteen wo- 
men delivered at the Dublin hospital, under charge of Dr 
Collins, thirty-three had face presentations, and four of 
them had still born children, which is a little less than 
twelve per cent of mortality in this labour. I have said 
enough in my observations On Face Presentations, at 
page 201 et seq., to make it unnecessary for me to repeat 
any thing here, in relation to the difficulties of that sort of 
birth. It is merely proper for me to remark that the for- 
ceps, when their use is indicated, must be applied to the 
sides of the head by carrying the points of the blades up 
to the vertex nearly. In those examples in which the chin 
comes to the pubis, the handles need not be very much 
depressed ; but in those in which the forehead is at the 
pubis, the handles must be at first very strongly depressed, 
and as the case proceeds, they must be strongly elevated, 
so as to get the chin down to the fourchette, over which 
it must slip, and then begin at once to approach the breast 
again, in the act of flexion. As soon as the chin is free, 
we allow the handles to descend again, while we con- 
tinue the traction until the head is completely emerged. 
1 shall take this opportunity for stating, that I conceive 
it to be impossible, to have a better instrument for this 
particular labour, than Davis's forceps, as made by Bot- 
schan, 35 Worship street, London. This instrument 
holds the head as in a basket, and is far less likely than 
any other with which I am acquainted, to bruise or in 
any way injure the child. The figures show very clearly 
the difference between a face case, in which the chin 



312 OF THE FORCEPS. 

comes to the pubis, and one in wliich the forehead is 
there, as well as the manner in which the head is taken 
hold of by the forceps. 

The head is said to be locked^ whenever two oppo- 
site sides of it are caught by two opposite sides of the 
pelvis, and held so firmly there, that it can descend no 
lower, and either cannot, or cannot without great diffi- 
culty, be pushed upwards again into a freer or larger 
space. In general, when the head is thus locked, it is 
in its transverse or bi-parietal diameter, one parietal pro- 
tuberance being held at the pubis, and the other at the 
projection of the sacrum. Suppf)sing the pelvis to be 
only three and a half inches in its antero-poslerior diam- 
eter, and the head to be three and three quarters in its 
smallest diameter, then it might happen, as it does in fact 
happen, that the cone of the head should be driven by 
the force of the pains, long continued, into the narrow 
pass, the delicate bones of the head giving way, and be- 
coming indented under the pressure of the promontory 
of the sacrum, and moving downwards until it be- 
comes immovably fixeil and held fast by the opposing 
points of the pubis. This state would constitute whatis 
called a locked head. Many evils result from this lock- 
ing of the head. For example, the woman, after vain 
efforts, and very great suffering, becomes feverish, and 
at length loses her pains altogether, or a state of con- 
stitutional irritation comes on, marked by a frequent, 
small pulse, coolness of the extremities, sunken or ca- 
daverous appearance of the face, jactitation, vomiting, 
and if not soon relieved, followed by death, which hastens 
at rapid strides to end the strife. The pressure destroys 
the child; it also produces the death of the parts of the 
mother that are conifrressed betwixt the pubal or sacral 
bones and the child's cranium ; or it causes inflammation 
to take place, to be succeeded by sloughing and its conse^ 
quences. Or, the urethra being effectually compressed 
betwixt the cranium of the fostus and the symphysis pu- 
bis, a total suppression of urine takes place, followed by 
its very serious consequences ; or lastly, the soft parts, 
perhaps the vagina, or possibly the womb, being pinched 
as above stated, may give way during a pain, and the 



OF THE FORCEPS. 313 

laceration, once begun, may extend so far as to allow 
the child to escape into the peritoneal sac. 

Whenever, then, the head is found to be so situated 
that it will neither advance nor retreat, it may be said to 
be locked, and the case ought to command the greatest 
care from the medical attendant. 

It is manifest, that if the arresting points of the pel- 
vis touch the head at its parietal protuberances, no pos- 
sibility exists of applying the forceps in that direction ; 
there is not space enough to admit of the blades, and if 
they are to be applied to the head, it can only be on 
those parts that are free from great pressure, as the face, 
upon one side, and the occiput, on the other ; and this 
must be done notwithstanding any fear we entertain 
of contusions upon the face^ of which there is some risk, 
but which very risk becomes less as it is the more con- 
stantly borne in mind. 

When the attempt to deliver in this case is about to be 
begun, the forceps should be well pressed together, so that 
when the lever-like movement takes place, their blades 
may not be allowed to slip or slide upon the face, which 
would thereby be very liable to excoriation, or even to 
be cut by their edges, formed, as is well known, for ap- 
plication to a convexity different from that of the face. 
The motion from handle to handle, assisted by a suffi- 
ciently powerful traction, will, ordinarily, succeed in dis- 
engaging the head, and getting it down into the excava- 
tion ; upon which, the blades ought to be removed, and, 
if the pains are revived andprove strong enough — they 
need not to be re-applied ; but, in the lack of a proper 
force, they should be adjusted anew, and on the sides 
of the head, which is the part for which their curves 
were fashioned, and to which only they are really adap 
ted. 

In making compression, let it be carefully remembered 
that that compression is not designed for the purpose of 
diminishing the diameters, but only to hold the object 
more securely or steadily ; any amount of compressive 
action beyond this indispensable one, is mischievous, as 
tending to augment the difficulty, by forcing the parietal 
protuberances more decidedly against the arresting points. 
2 b 



314 or THE FORCEPS. 

[ succeeded by this means in drawing a head through 
a pelvis so faulty in its antero-posterior diameter, that I 
could readily touch the sacrum, by introducing only the 
forefinger into the vagina. The patient was a very small 
woman of colour, to whom I was called, in consultation 
by a young medical friend ; the child was dead, but not 
injured by the instruQient. So great was the difficulty, 
that I at one period, entertained very seriously the idea 
of performing the embryulcia. In these cases, the ope- 
rator, who alone can estimate the degree of force he 
employs, is the sole judge, as to whether that force is 
too great to be compatible with the safety of the woman: 
should he, upon a due consideration of it, deem it wholly 
unsafe to proceed, or impracticable to succeed by any 
legitimate exertion of his strength, there remains the 
resource, sad as it is, of the perforator. Now that we 
have the advantage of the stethoscope, we can, with great 
certainty, determine the question of the life or death of 
the fcetus in utero ; and where we find, upon auscultation, 
that its life is extinct, we need have but little hesitation 
in applying the perforator, in order to reduce the size of 
the scull, by extracting its contents. In doing this, 
however unpleasant the operation, we effectually remove 
all danger arising from a further continuance of the pres- 
sure on the soft parts of the mother. In case the stetho- 
scope reveals the fact, that the fcetus is still living, we 
should feel constrained to wait so long, as to overstep, 
perhaps, the boundaries of prudence. 

But it does not always happen that the head is lock- 
ed in the direction and situation above pointed out. 
The vertex may be jammed down behind the pubis, and 
the forehead in front of the promontory. Here the for- 
ceps can be legitimately adjusted, and admit of the appli- 
cation of a greater force, and it \v\\\ be probably found 
less difficult to unlock and rotate the head, in conse- 
quence of the greater convexity of the points of arrest. 
Some degree of rotation ought to be given to the head 
by means of the forceps until they succeed in getting it 
down into the excavation, when it may be rotated back 
again to the arch of the pubis, and so withdrawn. 



OF THE FORCEPS. 315 



Impaction of the head cannot take place at the supe- 
rior strait; the shape of that opening is such that its 
whole circumference cannot be filled by the head of a 
child ; there would always be found a partof itin which 
not only the blade of a forceps, but a couple of fingers 
would find passage ; but after the head has sunk below the 
strait; the conical figure of the excavation, perhaps ad- 
mits of its whole circumference being occupied by the 
head, which fills it up completely, and so completely, 
that the forceps can find no space in which to pass. Let 
the attempt, however, be made, in every unavoidable 
case, and when it fails of success, the head can be open- 
ed, and the skull made to collapse. 



It only remains for me to relate the manner of apply- 
ing the forceps in breech or footling cases, wherein the 
head refuses to come away after the shoulders are de> 
livered. I have already said, that it is my invariable 
rule, to have the forceps in readiness in every instance 
in which I discover that the head is to be the part last 
born. 

When the instrument is wanted for such a use, it is 
wanted suddenly — -immediately ; and the medical at- 
tendant fails in his duly, who finds himself in want of 
forceps for this purpose, and is obliged to send for them; 
for a child perishes, v/hile a messenger is going a hun- 
dred yards, or putting on his boots. 

There is no need for my going again at length, over 
the causes that render the forceps necessary on these 
occasions. It is enough, that the expulsive powers are 
wanting, either from disproportion, from cessation of 
efTorts both voluntary and involuntary, or from mal-po- 
silion. If the head continues undelivered but a few 
minutes, the child is lost. 

Supposing that the shoulders are delivered, and the 
face in the hollow of the sacrum; let a napkin be wrap- 



316 OF THE FORCEPS. 

ped round the body of the child, including the arms, 
which should be placed against its sides, so as to keep 
them out of the way. — Then, giving the body to an as- 
sistant, let it be held nearly perpendicular by the thighs 
or hips, so as to press the nucha against the arch of the 
pubis. The left hand blade, guided by two fingers of 
the right hand, is to be then passed in at the left side of 
the vagina, and applied to the head, covering it in the 
direction from chin to vertex. The right hand branch 
is next introduced, with similar precautions, into the in- 
ferior and right side of the vagina, and so conducted on to 
the head, as to embrace it from chin to vertex. As soon 
as the instrument locks, the tractions are to be commen- 
ced, and there will be, in general, little delay in the ex- 
traction, if the handles be raised as the head emerges; 
they requiring to be elevated, just as is needful in the 
delivery of occipito-anterior positions. 

But — if the child be unfortunately born with the toes 
towards the pubis, and rotation in the subsequent stages 
cannot be effected, so that the face is uppermost ; if 
in this case, vain attempts to deliver by the hand have 
been tried; then, let the woman lie on her left side, 
with the thighs strongly flexed ; let the child be turned 
back as far as it can be done with safety to its neck, 
so as to bend the neck very much backwards. By this 
position, the forceps can be introduced in front of the 
child, the left hand branch being first passed up on 
the left side of the chin and carried as far as the ver- 
tex ; while the female branch is introduced upon the 
opposite side so far as to allow of its being locked with 
the pivot. As soon as the head is properly seized, let 
it be drawn downwards in such a direction as to cause 
the chin to emerge under the arch ; to which end, let 
the handles be at first somewhat lowered. 

Where it can be effected with proper celerity, it is 
better for this application of the forceps, to bring the 
woman to the edge of the bed, and allowing the peri- 
neum to project beyond it, cause her feet to be suppor- 
ted in the usual manner. The child, wrapped in a 
napkin, can be well entrusted to a kneeling assistant, as 
it is held nearly in a vertical or standing position. The 



OF THE FORCEPS. 317 

brandies of the instrument have, by this means, free 
access to the left and right sides of the vagina, and they 
lock wiih the greatest ease in front of the throat. Ex- 
cept in such a position of the woman, I cannot conceive 
how it would be practicable to use the long forceps; but 
Haighton's or Davis's forceps could be applied while on 
the side very easily. 



Perhaps there is nothing to be met with in the very 
troublesome and anxious profession of an obstetrician, 
that is more piiinful to his feelings, than the manage- 
ment of a case of labour, in which it is required to muti- 
late the child, in order to extract it from the maternal 
organs. It is fortunate that this odious duty does not 
occur very frequently ; and we are indebted to the in- 
ventor of the forceps, Chamberlayne, for an exemption 
from it in the present age, in numerous instances, in 
which, without the important uses of that instrument, 
we should be compelled to resort to the perforator and 
the hook, which comprised nearly the sum of the in- 
strumental resources of the ancients. We are also in 
modern times highly favoured by the application of the 
stethoscope, or direct auscultation, for greater certainty 
relative to the life of the foetus, whose state of life or 
death can now be very accurately determined by that 
means ; thus relieving the mind of a most painful solici- 
tude by the certainty of its death, if that event should 
have happened, in cases in which we are compelled to 
apply destructive instruments for its delivery. 

When the fcetal head is driven into the pelvis, and 
arrested there in consequence of disproportion of its dia- 
meters to those of the bony canal through which it is to 
be transmitted; if the arrest cannot be obviated by the 
hand, the lever or the forceps, there is danger that the 
mother may suffer so much constitutional irritation from 
the fruitless efforts she makes, and the agonizing pain 
she endures, as to sink into exhaustion, and perish with 
the child still undelivered. But even in those instances 
in which she is not threatened with exhaustion, she is 
2 B* 



318 OF THE FORCEPS. 

liable, from the pressure of the head, to have inflamma- 
tion or gangrene of the soft parts, which are contused by 
it, or she is exposed to the danger of lacerations of the 
womb itself, or of the vagina, whose consequences are 
greatly to be feared and deprecated. 

Exhaustion, manifested by cessation of the pains, 
smalhiess and great frequency of the pulse, a haggard 
and sunken countenance, anxiety, jactitation, coldness 
of the extremities, profuse viscid sweats, and delirium- 
all these may come on, in labours that are drawn out 
too long from smallness of the pelvis, and from rigidity 
of the soft parts; cases in which we may discern, very 
clearly, the necessity of immediate delivery, to rescue 
the woman from impending death. When such signs 
are present, and the child is known to be dead, if the 
ergot and the forceps are found, upon trial, to be una- 
vailing, recourse must be had to the most speedy means 
of relief, to wit, the opening of the head, and dis- 
charge of its contents, with a view to the collapse of the 
cranium. This object is effected by the introduction 
into one of the fontanels or sutures, of the perforator, 
commonly called Smeilie's scissors, the blades of which 
being opened, make a free incision, through which, if 
enlarged by a crucial cut, the cerebral contents are either 
extracted at once, or allowed to escape slowly under 
the pressure of the pains. As soon as the opening is 
made, it is common to push the perforator deep into 
the cavity of the cranium, or to introduce a crotchet so 
as to break up the textures within, and then, seizing 
the head by means of the sharp hook, which is applied 
to any convenient situation on the outside or in the inside 
of the skull, to drag it through the vulva, and deliver it ; 
after which, if the woman have not suffered too severely, 
she soon recovers of the effects of her preceding fa- 
tigue, and severe pains. 

This is the simplest and easiest case of embryulcia, 
and is one that any humane practitioner would, or might 
perform, without hesitation, upon the proper grounds 
for the proceeding being fully set forth to him. 

Yet, notwithstanding the facility with which the opera- 
tion of embryulcia may be performed, it is one so unnatu- 



OF THE FORCEPS. 319 

ral, and so shocking to the feelings of all concerned, that it 
ought not to be performed without very satisfactory rea- 
sons for it; and in general, not without consultation and 
agreement with a medical brother. In those instances 
in which it becomes necessary, during the life of the 
child, to resort to this mode of delivery, the most formal 
consultation ought to be regarded as indispensable ; and 
no such consultation can be supposed to result in such a 
proceeding, except upon the most urgent and clearly 
understood reasons for it. 

There are cases of labour occurring in women with 
deformed pelvis, that are plainly impracticable with an 
unmutilated child. For example, if a woman have the 
pelvis occupied with an exostosis, or if the diameters of 
that canal are changed and spoiled by rachitis or by 
nialacosteon, the child contained within her womb can- 
not escape whole per vias naturales. If the promontory 
of the sacrum comes within two inches and a half of the 
symphysis pubis, the child cannot pass the strait, be- 
cause its smallest diameter is three and a half inches ; 
and indeed, if the pelvis have three inches of antero- 
posterior diameter, it cannot be born, unless it be un- 
commonly small; and moreover possessing a very in- 
complete ossification of the cranial bones, and great 
laxity of the suture lines that unite them : such a head 
might, by long pressure under a very powerful womb, 
be at length forced down through the strait, after it has 
been moulded into the proper form by the force applied 
to it. Yet, when we come to consider, that the bi-pari- 
etal diameter is three and a half inches, we shall enter- 
tain little hope of getting the head down, in a pelvis of 
three inches. It is very true, that Sola5^res, and Duges, 
and others, have been fortunate enough to meet with 
cases in which the head, at term, has been born in a 
pelvis of two and a half inches from front to rear; but it 
is not to be expected that success can attend labour in 
a female whose pelvic deformity even approaches to 
two inches and a half in its smallest line of diameter. 
The exceptions but prove the general rule. 

Such a pelvis is not fit for the forceps ; since it is too 
small for them to be withdrawn when locked. The ques- 



320 OF THE FORCEPS. 

tion must always be, therefore, between the perforator and 
crotchet on the one hand, and the Cesarean section on 
the other. But this is only to be considered as relative 
to the living child. Of the dead child, no question can 
arise, as to the mode of its delivery, except that of the 
perforator, and whether sooner or later. The dead 
child must always be withdrawn per vias naturales, if 
there be space enough to extract it through. But even 
where the child is known to be dead, we may be com- 
pelled to perform the Cesarean operation, if we would 
deliver the woman at all, since deformity may reach to 
the degree of shutting up the passage, even against the 
perforator. There is in the University of Pennsylvania, 
a pelvis so distorted, that the hand could not possibly 
have directed an instrument to the head, in a manner to 
enable the surgeon to open and extract it. The woman 
from whose remains the pelvis was taken, died in the 
Almshouse, resolutely rejecting the Cesarean operation, 
and preferring to it, the death which she knew to be in- 
evitable. 

The practitioner who may be in charge of a case of 
labour where embryulcia is indicated, must be guided by 
his judgment, and the counsel of his medical brother, as 
to the signs which compel him to undertake the delivery. 
I have already enumerated them — and they are easy to 
be understood. There is, in general, far more danger of 
the operation being deferred too long, than of its being 
performed too soon, since, if it be not performed in time 
to save the life of the mother, it would be as well not to 
do it at all. I know, that in uttering this sentiment, I 
am liable to the imputation of wantonly encouraging the 
use of this dreadful operation, but I wish to disclaim 
such an intention. I hope that no man living is more 
reluctant than I am to use any obstetric instrument what- 
ever; and I fear that the resort to their employment is 
often had, very unnecessarily and rashly. But, I con- 
sider, that when the case under consideration arises, M-e 
ought to act so promptly and so understandingly, that 
we may, on the one hand, derive a perfect success from 
it, and on the other, stand acquitted, in our own judg- 
ment, and in that of others, from the charge of any rash- 



OF THE FORCEPS. 321 

ness or precipitation. I shall strive, therefore, while I 
reiterate the opinion, to clear myself by repeating, that all 
such cases require a medical consultation. To mutilate 
the child, and then lose the mother, is a real misfortune, 
both for the practitioner himself and for the profession, 
which is by such results in danger of falling into disre- 
pute. 

It is to be understood, then, that where all other in- 
strumental means fail — where, after due reflection upon 
the circumstances that hinder the delivery, a conclusion 
is formed that the mother and child must both perish, 
unless the latter be withdrawn by the assistance of in- 
struments that mutilate it — where the Cesarean opera- 
tion is inadmissible, or rejected by the patient, we have 
the remaining, and very sure resource of the operation 
of embryulcia, or embryotomy ; and we can venture to 
encourage and cheer the unhappy and suffering female, 
with the prospect of speedy relief by its means. 

I have had occasion to feel, in common with other 
practitioners, how dangerous an instrument is the sharp 
crotchet. The force to be employed on it, in extraction, 
is so great, that should the point slip from, or tear out 
of the bone, it is always jerked downwards several inch- 
es, and is very apt to catch in some of the soft parts of 
the mother, which are ploughed up and lacerated by it. 
How easy it would be to lacerate the vagina, or even the 
lower part of the wcmb, by the slipping of the point; 
and nevertheless, he who uses the crotchet, and is per- 
fectly aware of the risk, is under the necessity of run- 
ning that risk wlienever he takes the instrument in his 
liand to deliver with it. There is no part of the cranium 
to which it can be applied, without some hazard of its 
losing its hold. This is most apt to occur from the faulty 
manner in which the crotchet is generally made, viz. 
with iron, and not with steel. With a point of soft iron 
there is no real security ; because, the point soon be- 
comes dull, and does not maintain its hold of the bone. 
The point ought to consist of well tempered steel, and 
should be made as sharp as possible — but very much 
bevelled. 

There is a vast variety of instruments prepared for the 
delivery of the head, in cases of deformed pelvis. Dr 



322 OF THE FORCEPS. 

Davis of London has invented a great number of them, 
some of which I have had occasion to use, but with less 
satisfaction than I expected to Jiave, from the strong re- 
commendation bestowed upon them. I am now well 
convinced, that a great apparatus of this sort is not at all 
necessary, as I think will be convincingly shown in the 
sequel of this article, in which, I shall describe an in- 
strument capable, with the occasional aid of one sharp 
crotchet and a perforator, of effecting the delivery of the 
head in the most restricted pelvis from which delivery 
is at all possible. 

As this volume is not designed to be drawn out to a 
great length, I am constrained to make many of the re- 
marks that I could otherwise find occasion to otfer, more 
brief than is compatible with a copious detail of the sub- 
jects. This necessity induces me to give at length, 
the history of a case of labour in a deformed pelvis that 
was under my care in the year 1831. It was drawn up 
by my friend Dr George Fox, and published in the North 
American Medical and Surgical Journal, vol. Xll. page 
484. It may, perhaps, serve sufficiently well, to set 
forth the difficulties and embarrassments with which 
such cases are surrounded, and the success of it, proba- 
bly the most difficult obstetric operation ever performed 
in this country, may encourage those who shall here- 
after have the misfortune to contend with similar cases, 
to hope for success, in the midst of the greatest obsta- 
cles. I consider it more instructive than any merely 
didactic remarks that I could compress into these pages. 

"On Tuesday, June I4th, 1831, I was called about 

seven A. M. to see Mrs R in labour with her first 

child ; this is stated to have commenced about one A.M. 
The pains, as are usual in the commencement of labour, 
were feeble, short, and at about ten minutes interval. 
Upon examination per vaginam, the projection of the 
sacrnm was immediately felt: not, however, suspecting 
the deformity which was subsequently found to exist; 
this was not at tlie time particularly attended to, the os 
uteri was sufficiently dilated to admit the finger and feel 
the protruding membrane. I was struck with the form 
of the sacrum : the rectum being very much distended 



OF THE FORCEPS. 323 

with feces, I thought it might, in part, be occasioned by 
this. Directed ol. ricini one ounce, which was taken 
immediately: at noon found, upon examination per va- 
ginam, that the membranes had ruptured, the head pre- 
senting: she was not aware at what time the waters had 
escaped. In the evening, the rectum being unloaded by 
the operation of the oil, I made a more minute examina- 
tion, and was sensible of great deformity of the pelvis, 
though not to the extent we afterwards ascertained, the 
pains not being at all active. As it was late, I deter- 
mined not to ask the assistance of my medical brethren 
till the following morning; therefore directed an ano- 
dyne (which I subsequently ascertained was not taken, 
from her dislike to laudanum and fear of its retarding 
her labour) and left her for the night. Was called up 
about one o'clock the next morning, her pains being 
more frequent and stronger; found the os uteri rather 
more dilated, and the external parts very rigid, prevent- 
ing an accurate examination of the pelvis ; I remained 
with her some hours ; subsequently called upon Dr 
James, who met me in consultation at half past eight A. 
M. In consequence of the rigidity of the soft parts, we 
found it impossible to make any satisfactory examina- 
tion ; we therefore concluded it best she should be bled 
and take an anodyne — that we would meet in the after- 
noon: she was accordingly placed erect in bed and bled 
to incipient syncope, which was after losing about fifteen 
ounces; twenty drops of laudanum were soon after 
given. In the afternoon Dr James again saw her: from 
as accurate an examination as we were capable of mak- 
ing (for the external parts still continued rigid, though 
somewhat relaxed since the bleeding), we came to the 
conclusion that there were not at most three inches in 
the antero-posterior diameter; that laterally there was 
rather more room, on the left more than on the right; 
the posterior lip of the os uteri was swoln and succulent, 
forming a cushion in front and a little below the projec- 
tion of the sacrum ; the head was presenting to the left 
side, its exact position could not be determined. On 
account of the unusual interest of the case, Drs Meigs 
and Lukens were invited to attend ; Dr James not feel- 



324 OF THE FORCEPS. 

ing quite well, did not meet us that night: the result of 
the examination of these gentlemen was, that there was 
not more, if as much room at the superior strait as we 
supposed ; they coincided with us in the opinion that it 
was impossible the child should be born alive per vias 
naturales: our next object, therefore, was to ascertain 
whether or not the child was living; this was rendered 
certain by the application of the stethoscope ; the pulsa- 
tions of the child's heart were distinctly perceived, 
whilst the placental souffle was also very evident ; the 
pains continued as they had been most of the day, re- 
curring every four or five minutes : we remained with 
her some hours, when we ordered her an opiate, and 
agreed to meet at four A. M. The result of this meet- 
ing was, that as the proper means of proceeding were of 
such immense importance, further advice should be had, 
and that we should meet at half past eight o'clock A. M. 
Dr Physick was called on, but was confined to the house 
by sickness ; Dr Dewees was also called for, but was 
absent from the city. At half past eight A. M. Dr James 
met us, Dr llewson being added to the consultation : it 
was agreed as before stated, that it was impossible the 
female should be delivered of a living child per vias natu- 
rales ; the question then was, whether the child should 
be sacrificed to save the mother's life, or an attempt 
made to save both mother and child. It was concluded, 
as the strength of our patient was good, her pulse only 
eighty-four and strong, as there were no symptoms of 
constitutional irritation, no injury would result from a 
few hours delay; we therefore separated to meet at 
twelve M. 

" The consultation was held at the appointed hour ; by 
this time, after repeated and the most accurate examina- 
tions that the case admitted of, we were unanimous in 
the opinion, that there were not more than two inches in 
the antero-posterior diameter, most probably only one 
inch and three-quarters ; the different methods of pro- 
ceeding which have been proposed in similar cases were 
duly and maturely considered, viz. the division of the 
symphysis pubis, the Cesarean operation and cephalo- 
tomy ; the first was considered inapplicable to the pre- 



OF THE FORCEPS. 325 

sent case; the Cesarean operation was thought to be at- 
tended with so much risk to the mother, as almost to be 
necessarily fatal, some of the most distinguished sur- 
geons being decidedly opposed to its performance. Dr 
Physick, who was called upon in the course of the morn- 
ing by Dr Meigs and myself to ask his opinion on the 
propriety of this operation, was decided and positive in 
his opposition to it; under the weight of such authority, 
the idea of the Cesarean operation was abandoned. It 
was therefore concluded, after the most mature delibera- 
tion, and upon viewing the case in all its bearings, that 
the life of an imperfect being (for it was again ascertain- 
ed that the child was living and apparently vigorous) 
should be sacrificed to save the life of a wife and daugh- 
ter, and that the operation should be immediately com- 
menced, by opening the child's head, breaking up the 
brain, and allowing some hours to elapse before attempt- 
ing extraction ; at my request, with the approbation of 
our colleagues, Dr Meigs consented to perform it; Drs 
James and Hewson having professional engagements 
were at this time obliged to leave us, to meet again at 
six o'clock, P. M. Preparatory to the operation, the 
rectum was unloaded by an enema, the urine drawn off 
by a catheter, and an anodyne administered ; her pulse 
was one hundred and four. The consent of the patient, 
her husband and friends having been obtained, she was 
placed at the foot of the bed (which had previously been 
adjusted), the hips being on the edge, so that the peri- 
neum was perfectly free, an assistant supporting each 
leg; Dr Meigs then took his seat directly opposite, 
made another examination preparatory to beginning the 
operation ; after having some time carefully examined, 
he called me, and subsequently Dr Lukens also, to 
make another examination, the result of which was, that 
the operation of cephalotomy, if not altogether incom- 
petent to the delivery, would be attended with as much 
risk to the life of the mother as the Cesarean operation; 
it then appeared to us impossible that the cranium should 
be removed and the base brought through the superior 
strait, without the most violent exertions and great dan- 
ger of lacerating the cervix uteri, vagina, &c. ; that tak- 
2 c 



326 OF THE FORCEPS. 

ing this view of the case, it was better to call our col- 
leagues again together, at as early an hour as possible, 
to reconsider the propriety of performing the Cesarean 
operation : the child was again ascertained to be alive. 

" Accordingly at five P. M. we again met ; Dr J. Rhea 
Barton at this time saw our patient; our first object was 
to ascertain respecting the life of the child, and upon 
applying the ear and the stethoscope, no pulsation was 
perceptible in any part of the uterine region ; it was then 
unanimously agreed (the female not having felt the child 
for two or three hours) that it was dead: there was now 
no further hesitation as to the propriety of cephalotomy, 
which was immediately performed by Dr Meigs, who 
employed the utmost assiduity and care in the manage- 
ment of the operation, on whose skill and unwearied at- 
tention the success of it is mainly dependent ; to him I 
am also indebted for the following account of the diffi- 
culties, (fcc. which were experienced in the accomplish- 
ment of the delivery of the child. 

" * The woman being conveniently placed on her 
back, with the perineum projecting beyond the edge of 
the bed, and the legs and feet properly supported by an 
assistant on each side, I took my seat for the purpose of 
proceeding with the first part of the operation, the per- 
foration of the cranium. 

" ' A suture crossed the pelvis from front to rear, but 
its edges were overlapped and could afford no facilities 
for the operation. This suture was the right leg of the 
lambdoidal, as was afterwards ascertained. 

" ' With Botschan's improved craniotomy scissors, I 
endearoured to penetrate the solid bone in the centre of 
the strait, but owing to the narrowness of the passage, 
and the constant interference of the os uteri, the lips of 
which were nearly in contact antero-posteriorly, I dared 
not to give to the instrument that rotatory or drill-like 
motion which was necessary, for without such a move- 
ment it was impossible to make any progress, as the 
head rose upwards and rolled freely in the superior basin 
whenever any considerable pressure was applied by the 
perforator, though the womb seemed to be pretty firmly 
contracted at the same time. 



OF THE FORCEPS. 327 

" * Finding this mode of proceeding unsafe for the 
woman, I begged permission to leave her a few minutes 
in order to procure an instrument better adapted to the 
purpose in hand. Accordingly, Mr Rorer furnished me 
with a large trocar with a triangular point, and having 
guided it with two fingers to the proper situation and 
kept it securely by retaining the fingers in contact with 
the head, I was able gradually to drill a hole through 
the bone, the head being pressed from above against the 
strait by Dr Lukens. Two other perforations were 
made near to the first one, in the same cautious manner; 
after which, I again introduced Botschan's scissors, and 
having opened them, found that I had made an incision 
of about an inch and a half in length. Through this a 
slender blunt hook was introduced into the cavity of the 
cranium and the brain very freely broken up. 

" * The poor woman, who M'as already very much ex- 
hausted by many hours of labour, now took an anodyne 
and was left to her repose, in order that the medullary 
matter might be gradually pressed out, and the cranium 
allowed to collapse so as to come more in reach of the 
instruments. 

*' ' At ten o'clock P. M., I again met Drs Fox and Lu- 
kens, and the woman being disposed as before on her 
back, I introduced a crotchet into the cavity of the cra- 
nium, and spent some time in extracting the medullary 
substance, not much of which seemed to have been ex- 
pressed during our absence ; the head still continued on 
the superior strait, except a portion of the hind head 
which was passed down into the excavation to the left 
of the promontory, where there appeared to be the larg- 
est space. 

" ' Having removed a considerable quantity of the ce- 
rebral substance, I fixed the tooth of the crotchet into 
the cranium, and guarding it on the outside with a fin- 
ger, exerted a very great amount of force, which had not 
the least eff'cct in drawing it lower down. 

" 'It soon became evident to me, from several trials 
of this kind, that no exertion of mere strength could be 
of any avail to drag away the head, and if it was to be 



328 OF THE FORCEPS. 

delivered at all, it must be piece meal: but as the child 
had been dead only a few hours, and its skull bones were 
still firmly united to their inner and outer membranes, 
it will be readily conceived that the removal of the bones 
was a most difficult matter, not only on account of the 
firmness of their connexions, but also on account of the 
narrowness of the passages, the great hardness of the 
skull, and the great danger of wounding the parts by the 
slipping of the crotchet, which, under the circumstances, 
could be best applied on the interior of the skull, and 
from the swoln and succulent state of the lips of the os 
uteri, whose inner surfaces were in contact, and presen- 
ted to the touch, the idea of a long fissure, instead of 
preserving a round or oval form : last and not least, 
the perineum was so strong and unyielding, that the 
greatest inconvenience arose from its pressing the fingers 
against the arch of the pubis with such force and so 
painfully, that no one could endure for any great length 
of time to keep up the necessary extension. 

" ' Being possessed of one of Dr Davis's osteotomists, 
I expected to derive great advantages from its employ- 
ment in the case, and accordingly introduced it with the 
view of cutting away portions of the bone, but the con- 
stricted state of the parts rendered it impossible to make 
use of it consistently with a humane regard to the safety 
of the patient. 

" ' Having ascertained, then, by fair experiment, that 
mere force could do nothing in the delivery, I resolved 
to pursue the intention of breaking up the head by means 
of the crotchet; and it was with great fatigue to the 
woman, that I picked out altogether about as much as 
would equal the size of one of the parietal bones, the 
portions consisting of fragments of the right parietal and 
part of the frontal bone. 

" ' Finding towards morning, that the progress of the 
operation was exceedingly slow, 1 went out and pro- 
cured a pair of straight tooth forceps, with which I 
could take a firm hold of the bone and twist off" portions, 
which after they were broken away, often took a good 
while to separate from their adhering membranes. 



! 

J 



OF THE FORCEPS. 329 

" * At four o'clock, the woman was so much fatigued 
that we agreed to give her an anodyne draught, and leave 
her to recover strength by means of a few hours' rest. 

" ' The attempts at extraction had now continued from 
ten o'clock P. M. until four A. M., and I think the 
whole of the bone removed would not much exceed in 
quantity one parietal bone at full term ; it seemed im- 
possible to proceed with greater rapidity, and I often ad- 
mitted a .doubt, whether I should be able to deliver her 
before death should come to her relief. 

" ' Throughout the day, on Friday, the attempts at 
extraction were repeated, in presence of the gentlemen 
last named, and also of Drs James and Hewson, who 
became fully satisfied, that no greater progress could at 
present be made, considering the circumstances of the 
woman. 

" ' Early in the afternoon, symptoms of fever became 
very manifest; the pulse rising to one hundred and 
twelve strokes in the minute, with considerable firmness 
and volume ; this state of the circulation being coinci- 
dent with a distressing eructation partaking somewhat 
of the character of singultus, a great distension of the 
abdomen, as well as of the womb itself, from gases ex- 
tricated within them. She complained, also, of great 
soreness of the belly, on which account she bad it bathed 
frequently with cold vinegar and water, leaving the sur- 
face exposed to the air. 

*' ' In order to counteract this new state of things, she 
was bled six ounces and took a portion of castor oil. 

" * Dr James who had witnessed in the morning the 
difficulty with which the extraction of portions of the 
cranium was effected, was good enough to supply me 
with a complete set of Dr Davis's craniotomy forceps, 
and returned to the house in the afternoon to our assist- 
ance. These instruments were applied, but they were 
incapable of eflfecting so much as even the straight tooth 
forceps. 'J'he teeth of the instrument could not be made 
to penetrate the skull, although most accurately adjust- 
ed ; and notwithstanding the handles were brought so 
nearly together, that the style on the one handle went 
quite to the bottom of the socket in the other, every at- 
2 c* 



330 OF THE FORCEPS. 

tempt to extract with them resulted in the slipping of 
the bone out of the gripe of the instrument; a proof at 
once of the hardness of the bone, and of the impossibility 
of bringing it down in its then condition. 

" * Putrefaction now rapidly advanced as indicated by 
the odour of the discharges, and my only hope for the 
escape of the patient rested on the opinion, that she 
might be supported a few hours, until the softening of 
the tissues should enable me to draw down larger por- 
tions of bone by admitting of the pericranium and dura 
mater being peeled off with a finger nail, while the bone 
should be secured, and drawn down with the forceps or 
crotchet. 

*' ' But such was the unpromising state of affairs, that 
the poor creature resolutely refused to make any further 
effort to escape, saying she knew that she must die, and 
would rather die than exert herself any further, and beg- 
ged in the most piteous tones that all further attempts 
to deliver her should be abandoned, yet expressing her 
thanks for the efforts that had been already made. 

*' ' She was at times slightly delirious. After ex- 
plaining to her the increased facility which began to 
exist, from the rapid decomposition of the foetus now 
going on, and endeavouring to reassure her with a pro- 
raise to deliver her in the course of the night, she was 
again left to rest three or four hours under an anodyne 
draught. During the whole period that has now been 
spoken of, the anterior lip of the os uteri was behind the 
triangular ligament of the pubis, and the posterior low 
down beneath the promontory, and strangulated, as it 
were, or buttoned by the part of the head that lay on the 
strait and partly within it: yet so swelled that their 
inner surfaces continued nearly in contact, except when 
parted by the introduction of the fingers. 

" ' The perineum seemed to have acquired no dispo- 
sition to relax, notwithstanding all the handling to which 
the parts had been subject; and, excepting that the 
bones were more easily detached now than before, no 
greater comfort or facility was enjoyed by the operator 
now than at the commencement. 

" ' At ten P. M., I again met Drs Fox and Lukens, 



i 



OF THE FORCEPS. 331 

and the patient, after much entreaty and argument, re- 
signed herself unwilhngly to the further proseeution of 
our attempts to deliver. 'I'he remains of the head were 
still high up, but some of the broken edges came lower 
down. I got hold of a piece that descended behind the 
pubis, and with the tooth forceps pulled it downwards, 
detacfiing the membranes as it advanced, and found that 
it consisted of all the remainder of the right parietal 
bone. I next got away nearly the whole left parietal, 
and afterwards with the crotchet removed first the right, 
and then the left orbitar portion of the os frontis, which 
was all that remained of that bone. I then got away 
with the crotchet and forceps, the right superior maxil- 
lary, and afterwards the left superior maxillary bone. 
I subsequently twisted off the greater part of the broad 
portion of the os occipitis, and the squamous parts of 
the temporal bones; so that I had nothing left now but 
the base of the skull and the lower jaw, which latter I 
left as a point on which to exert the tractions that were 
soon to be required. 

" ' If the estimate made by all the gentlemen, that the 
strait was not more than'tvvo inches in its antero-poste- 
rior diameter, should prove correct, I was fearful of 
meeting some difficulty in bringing the base of the skull, 
which was two and a half inches, through it; but when 
I had reduced the head so as to leave nothing more than 
the base of the skull and the lower jaw, I fixed a blunt 
hook into the latter, and with a finger to antagonize it, 
drew the mass down towards the point of the coccyx, 
and had the satisfaction to find that it was now quite 
through the strait. My hand being now introduced into 
the vagina, I got a firm hold of the neck, and with the 
exertion of the greatest strength, gradually brought the 
button-like remainder of the head out at the vulva, while 
the point of the thorax, of course, was entering the nar- 
row pass. The head was delivered at a quarter after 
one o'clock, and having succeeded in effecting tlie most 
difficult and dangerous part of the operation, she got 
some ergot; and fastening a twisted towel round the 
neck of the foetus, I renewed the extractive efforts, which 
in twenty minutes enabled me to deliver the shoulders. 



332 OF THE FORCEPS. 

and in twenty minutes more, the hips — the child being 
completely withdrawn at five minutes before two o'clock, 
which was forty minutes after the head was delivered. 

" * I found that, under the stimulation of the ergot, 
she was enabled to bear down very strongly, considering 
her exhausted state, and at all events, the chief object 
of its exhibition was secured, viz. a firm contraction of 
the womb, and an efTectual separation of the placenta, 
which came into the os uteri soon after the delivery. 

" * Large quantities of gas of the most putrid odour 
followed the extraction of the child, showing the en- 
largement of the womb, before spoken of, to have been 
owing to its extrication by the putrefactive processes 
going on in the uterine cavity. 

*' ' The cord was shrunk and black, and the placenta, 
which was also black, and filled with air, so as to cre- 
pitate under the fingers, was so horribly noisome that it 
was scarce possible to endure it during the requisite 
handling of it. No blood followed the placenta. 

" ' The body was soft and putrid, being completely 
emphysematous and crepitating like the placenta. The 
cuticle was peeled by the pressure and friction. 

" ' The child was rather above the medium size. 

*' ' After washing the poor creature with a sponge 
dipped in claret and water, and making her as dry and 
comfortable as possible, she got an anodyne and was 
left to rest, being unable to speak above a whisper, and 
with a pulse feeble, but beating only one hundred and 
two strokes per minute. 

" * The whole difficulty in delivering a child through 
so contracted a pelvis, can scarcely be conceived of by 
one who has not been engaged in such an operation. 
The constant and perplexing apprehension of injuring 
the mother, either with the instruments employed, or 
with the sharp and ragged edges of the bones which 
must be withdrawn, and sometimes violently broken off 
with the sharp tooth of the crotchet, involves the opera- 
tor in the most painful and unremitted attention and 
watchfulness. The confusion also in the parts, arising 
from the remains of the scalp and the inner and outer 
membranes of the cranium blending themselves, as it 



OF THE FORCEPS. 333 

were, with the os uteri, and covering and concealing the 
bones, is a source of great embarrassment, where those 
fibrous tissues retain so mucii lirmness and compactness. 

" ' Doubtless, could we have known that the woman 
would have been able to bear tlie fatigues of labour so 
long, we should have deferred the efforts at extraction 
for twenty-four hours after the perforation of the head; 
but such was not the opinion to be gathered from the 
actual phenomena. 

" ' It has been seen that no great loss of time took place, 
after the softening of the tissues rendered it possible to 
break them up with some facility, whereas the process 
previously was exceedingly slow^ and tedious. The 
perforation w'as deferred as long as possible, which 
saved us from the dreadful and cruel operation of cepha- 
lotoray in a living fcstus. The child died from long 
continued pressure.' 

*' June 18th, (Saturday) nine A. M. Our patient says 
she feels quite comfortable ; had some sleep after we 
left; pulse one hundred and twelve, rather more feeble; 
skin moist, tongue slightly furred; clean linen, &c., 
was put on her, and she was moved up in bed. The 
bladder was emptied by the catheter; fomentations with 
flaxseed mucilage directed to be applied to vulva, the 
most perfect rest and quiet strictly enjoined; as diet, 
arrow root and oatmeal gruels, tea and toast. 

*' Evening. Remains much the same; bladder again 
emptied; mucilages continued; an anodyne to be given 
at ten P. M., if at all restless. 

" 19th, nine A. M. Passed a comfortable night, pulse 
ninety-four, skin pleasant, tongue slightly furred, lochia 
almost natural; free from pain; slight soreness over 
pubis to left side, directed warm brandy to be applied 
over soreness, a seidlitz powder to be given, and repeat- 
ed, if necessary ; continue other means. 

" Evening. Medicine not having operated, an enema 
of warm flaxseed mucilage was directed, and an anodyne 
at bed time. 

"20lh. Rather restless in the early part of the night; 
enema operated freely ; feels very comfortable ; no pain ; 



334 or THE FORCEPS. 

pulse seventy-six; skin pleasant; tongue continues 
slightly furred ; countenance good ; spirits cheerful ; con- 
tinue as before. 

*'23d. Our patient continues to do well, usually rests 
well at night, free from pain, although the soreness in 
uterine region continues ; secretion of milk copious, 
feels so comfortable that she lias taken an infant to nurse, 
pulse rather more frequent than natural; tongue clean 
and moist, bowels costive, passes urine without diffi- 
culty, the catheter was used three times daily till last 
evening, when it was found to be unnecessary, lochia 
serous; directed ol. ricini, one ounce. Mucilages to 
vulva to be continued, mucilaginous injections per vagi- 
nara, continue diet, and perfect rest in horizontal posi- 
tion. 

" From this time our patient continued rapidly to im- 
prove ; in three weeks from the time of her delivery was 
so well as to be permitted to go down stairs, and in a 
short time resumed her ordinary avocations. 

" The subject of the preceding case is a native of 
Ireland, aged about twenty-two years, of small stature, 
not exceeding four feet and a half; is stated to have been 
a healthy child till her third year, when she received an 
injury by a fall, after which she was unable to stand or 
walk for two or three years ; at the expiration of this 
time she regained her strength, and was subsequently 
considered an active child. Upon examination, we 
found the femur and tibia of each extremity very much 
curved, forming a considerable arch forward; at the 
lower part of the spine, there was a cavity sufficiently 
large to admit the hand corresponding with the promon- 
tory of the sacrum internally; the bones of each arm 
partook of the general disease. It was evident she had 
in early life laboured under rickets." 



OF THE FORCEPS. 335 

In cases wliere tlie diameters of tlie pelvis have been 
so much diminished by rachitis or mollities ossium, as 
to render the descent of the fogtal head impracticable, it 
has been the universal custom either to perform gastro- 
tomy, or to lessen the size of the cranium by evacuating 
its contents, and then make extraction by means of the 
sharp crotchet. 

The method last spoken of is a good one, perhaps, 
and succeeds well enough where the diminution of the 
pelvic passages is not too considerable : nevertheless, 
we find, upon reference to the records, that a great many 
women have been the victims of such untoward labours, 
owing, measurably, to the violence done to the soft parts 
during the forcible extraction of the head, which was, 
perhaps, insufficiently reduced in size to admit of its 
transmission with safety to the mother — and probably in 
no less degree to the wounds that have been inflicted by 
the slipping of the crotchet, — a very common, and often 
unavoidable accident in its employment. 

The firm bony structure, composing the base of the 
fcetal skull, is nearly two inches and a half in its trans- 
verse or smallest diameter; mere excerebration, there- 
fore, cannot be regarded as furnishing a good security 
against fatal contusions from the forcible extraction of 
such a body from a pelvis whose smallest diameter is 
not exceeding two inches in length. Such a body as the 
base of the skull, must, in order to pass through such a 
pelvis, present itself in an inclined attitude, or with a 
dip, but this dip or inclination can be but imperfectly 
communicated to it whilst all the bones of the cranium 
retain their connection with each other. To enable such 
a base to pass downwards safely, the skull ought to be 
taken to pieces, and those pieces removed in succession. 
In some instances, this successive ablation of the cranial 
bones has been effected by the crotchet, the point of 
which was used to pick out the bones, sometimes in 
portions not larger than the finger nails ; as for exam- 
ple, in Elizabeth Sherwood's labour, so impressively 
narrated by Dr Osborne. Those who have perused that 
account, will remember the extreme perplexity of that 
practitioner, and the infinite pains he took in his anxiety 



336 OF THE FORCEPS. 

to avoid injuring her with the crotchet. He could not 
get the base of the cranium down until he had removed 
all the rest of the head. 

Having had occasion to observe the difficulties and 
perplexities arising from labour in deformed pelvis, as 
they occurred in Mrs M. R. of this city, the case above 
related, whom I have now delivered in two accouche- 
ments, I venture to lay before my professional brethren, 
with great deference for the judgment of older and more 
experienced men, the impressions I derived from observ- 
ing and conducting those two labours. 

There is reason to believe that no other female has 
ever been safely delivered in this country, under the 
disadvantages of a pelvis measuring only two inches from 
sacrum to pubis, which, by the judgment of persons of 
the highest claims to confidence, is the extent in Mrs 
R.'s case. I speak this, however, under liability to cor- 
rection. All the gentlemen then consulted, agreed that 
the diameter was as above mentioned. 

Her second accouchement took place in the month of 
June 1833, the child having reached the full term of 
utero-gestation, an event which I greatly deprecated, 
having vainly urged, with the advice of Dr Dewees, the 
operation for inducing premature delivery. 

The experience I had acquired in delivering her in 
the first labour, convinced me that the crotchet was not 
to be relied upon in her case ; not only because of the 
danger from contusion in extracting the skull, and from 
wounds made by the point of the crotchet, but also from 
the loss of time requisite for picking out the head bit by 
bit. The patient had almost fallen a victim to exhaus- 
tion in the first instance. 

In reflecting upon the facts that had occurred in 
1831, 1 found that the problem about to be solved in the 
second labour, was not, that, a head being retained above 
a pelvis too small to transmit it, to extract said head — but 
the question was, to extract said head with the smallest 
loss of time, and least possible risk to the mother. I 
had already ascerlained that the Cesarean operation 
would not be submitted to. 

I supposed that the head might be four inches in its 




337 



OF THE FORCEPS. 337 

bi-parietal diameter,* and I knew that the pelvis was 
only two inches. Under such circumstances the vertex 
will not present, but the crown of the head will be the 
presenting part: but since the cranium cannot recede 
farther than is necessary to bring it in close contact with 
the posterior part of the mother's abdomen, there will be 
two inches of the head lying upon the plane of the superior 
strait, and two other inches projecting in front of the 
symphisis pubis : or, in other words, the crown of the 
head will repose upon the top of the symphysis pubis — 
part of the head being behind, and part in front of that 
bone. 

This is -well illustrated in the accompanying figure, 
which was drawn by Mr Wm. Mason, and cut by Mr 
F. Gilbert, of this city. 

This wood cut is also intended to exhibit a very im- 
portant principle in the management of such a case, 
which is, that all that part of the cranium which lies in 
contact with the mother's back, is perpendicular to the 
opening of the strait^ and may, when the skull has been 
opened, be seized with a straight forceps or pliers, like 
that represented in the second wood cut; whereas, all 
that part of the skull that lies horizontally over the open- 
ing, can be taken hold of with a curved forceps or pliers, 
as is seen in the figure. 

I have found, upon applying the test of practice, 
that when the thin portions of the cranial structure are 
taken hold of, either with the straight or curved forceps, 
they can be broken up with great ease, and removed 
with sufficient celerity; so much, indeed, that a head 
may be reduced to a very small remainder in a short 
time. I believe that if early arrangements are made for 
delivering the patient by this method, no danger will 
exist of exhaustion or excessive constitutional irritation 
being produced, before the extraction of the fostus can 
be completed. 

From the foregoing remarks, it seems to be very clear, 



* I have measured many heads of children immediately after 
birth, that were four inches in the transverse diameter. 
3d 



338 OF THE FORCEPS. 

that the praoiitioner, in undertaking to deliver a patient 
with excessive distortion of the pelvis, ought to proceed 
to his operation with a full understanding, that after 
perforation, he is to remove all the posterior parts of the 
presentation with the straight pliers, and all the anterior 
and lateral ones, with the curved pliers ; making at- 
tempts, from time to time, to draw the head down, as 
he finds reason to believe that it is sufficiently broken 
up. Such are my views of the mode that ought to be 
adopted. I, at least, am fully of opinion that Mrs R. 
could not have been rescued by me, had I relied only 
upon the crotchet for her delivery. 

It is proper to observe, that the female constitution suf- 
fers less in the first hours of labour, in which the head 
cannot engage, than in those wherein the head sinks 
low into the excavation. This depends upon a well 
known principle, viz : that the contractions 'of the womb 
are violent and powerful in proportion as that organ be- 
comes smaller or more condensed. If the head becomes 
arrested in the excavation, and particularly, after having 
escaped from the uterine cavity, it is urged with great 
power upon the tissues, which resist its further descent. 
Under such circumstances, constitutional irritation is 
rapidly developed ; whereas, under the more lenient ex- 
ertions of the uterus, while the entire foetus is contained 
within its cavity,, not only is the impulsion of the head 
against the resisting tissues far more moderate, but in 
the intervals of the pains no pressure exists. Hence a 
woman remains long in labour, with little constitutional 
disturbance, in the kind of cases I am discussing. These 
observations are illustrated, and their truth confirmed, 
by reference to some of the most celebrated examples 
of such labours, which are recorded in the books. 

Whenever, therefore, a woman has fallen in labour, 
who is known to have an impracticable pelvis, and in 
whom the Caesarian operation is rejected — if the perfo- 
rator is to be resorted to, it should be applied as soon as 
possible, in order that, the cliild having ceased -to exist, 
all the facilities derivable from incipient decomposi- 
tion of the foetus may be enjoyed. Twenty-four hours 
after the death of the fcstus, the firmness and cohesion 




839 



I 



OF THE FORCEPS. 339 

of its soft parts are so much lessened by maceration, in 
an elevated temperature, equal probably to 99°, that the 
extraction of the pieces of bone is exceedingly easy. I 
should, therefore, in such difficult cases, recommend 
that all attempts to deliver should be delayed, if possible, 
for twenty-four hours after the perforation of the head. 
This recommendation is founded on what I have expe- 
rienced of difficulty in getting out the portions of bone 
after I had broken them up, when I made the attempt 
antecedently to the occurrence of signs of decompo- 
sition. The patient can be quieted with anodynes, and 
supported with light nourishment, and if needful may, 
by venesection and cold drinks, be kept tolerably free 
from vascular disturbance during the whole period of 
such delay as may be deemed advisable. 

I subjoin a cut which shows the form of the per- 
forator that I employed in Mrs R.'s case. It is a 
trocar or drill, ten inches in length from the handle to 
the point. I was obliged to make use of such a means 
of penetrating the skull, since no suture was practicable, 
and the common Smeliic's scissors could not be made 
to perforate the solid bone, any direct pressure causing 
the head to roll, or move upwards, and any rotatory or 
drill like motion with it, being impossible without great 
danger of wounding the lips of the os uteri. The same 
cut exhibits both the straight and curved pliers. They 
are eleven inches in length; the gripe is serrated and the 
sides of the mandibles are rounded, in order that they 
may not pinch any tissues except those intended to be 
included in the bite, which, on account of the serrae, is 
very sure and strong. 

I have never seen Baudelocque's (the younger) in- 
strument, ^owr hroyer la tele. Dr Davis's craniotomist, 
and his craniotomy forceps, were found incapable of 
useful application, upon several attempts that I made to 
use them in my cases. 



CHAPTER XVII 



INVERSION OF THE WOMB. 



When the womb is relaxed or uncontracted after the 
delivery of the child, no attempt ought to be made to 
talie away the after-birth, by pulling at the navel string. 
Should the placenta be still adherent to the fundus uteri, 
any tractions exerted on the cord, would tend to draw 
forth the after-birth, which might drag the fundus uteri 
along with it, and thus turn the organ inside out, or in- 
vert it. Inversion of the womb is one of the most 
dangerous accidents that can happen to a lying-in wo- 
man; it is always attended with severe pain, and the 
most violent hemorrhage, and if not early remedied, 
becomes irremediable, since it would be as easy to turn 
a non-gravid womb inside out, as to restore an inverted 
one, when many days have elapsed after the occurrence 
of the inversion. 

Those who have had the hand in utero, in turning, 
can well appreciate the exceeding laxity of the womb, 
when not affected with the pains; they can readily con- 
ceive that the mere weiglitofthe after-birth, still attached 
to the fundus, might cause a commencement of inversion, 
which could become complete by means of the woman's 
strong voluntary efforts to bear down her pains. It is 
not to be doubted that instances of inversion have oc- 
curred in which the practitioner deserved no further 
blame than that for not taking the proper precautions 
against its occurrence by a bandage and compress, and 



INVERSION OF THE WOMB. 341 

by commanding the patient to preserve the horizontal 
posture. 

Notwithstanding the occurrence might take place 
spontaneously, and immediately after the birth of the 
child, yet, in a major part of the examples, it has been 
produced by an improper haste and impatience to get 
away the after-birth. 

I have seen but two persons who have had inversio 
uteri, and they are both recovered; one, Mrs S., was 
already the mother of two children when she became 
again pregnant of the child born in June, 1831. 

It seems that having on both the preceding occasions 
suffered severely from the method adopted by the phy- 
sician in removing the after-birth, and supposing that a 
midwife would deal more gently with her, she engaged 
an old woman much accustomed, as it was said, to the 
care of women in labour, to attend her upon this occa- 
sion. The child was born by a very easy labour, but 
the after-birth not coming away so promptly as was 
desirable, tractions were made upon the cord which 
caused the after-birth to come into the vagina. This 
gave the patient exquisite pain. The midwife, who 
could not understand why the woman should suffer so 
severely, made haste to draw the placenta forth by the 
cord, which made her cry out so loud that it was said 
her voice was heard in the street. When the mass 
came away, the good woman found it still adhering to 
something, so that she could not take it up and put it 
into a basin. She therefore continued to pull at it with 
great force, not knowing that she held in her hand the 
after-birth still adhering to the fundus of the womb, 
which was now completely drawn forth and turned inside 
out. The hemorrhage was enormous, and the patient 
soon sunk into the extremest weakness and exhaustion. 
Half an hour elapsed before she thought proper to con- 
fess her incompetency to manage the case. I was sent for, 
after she had acknowledged her ignorance of the method 
of proceeding, and when I arrived the patient was with- 
out pulse — very cold, suffering the extremest distress, 
with constant jactitation, and a thirst that was unappea- 
sable. To all appearance the woman was in the agonies 
2 D* 



342 INVERSION OF THE WOMB. 

of death. I found the globe of the womb hanging down 
full half way to the knees, and still invested with the 
placenta and membranes, except those parts where they 
had been torn and broken by the attempts of the mid" 
wife to pull the entire mass away. 

I endeavoured to push the whole womb and placenta 
back into their natural position, but finding I could not 
succeed, I sent for my venerable friend Dr James, who 
speedily arrived. Dr James now made an attempt to 
reposit the womb, but he also failed. By his advice I 
then removed the placenta, but could not force the uterus 
up into the pelvis. 

In making tlie attempt to restore it to its place, I fol- 
lowed the method recommended in the books, that is, I 
compressed the organ in both the hands in order to 
reduce its size. At last I observed that the more I 
handled it, the firmer and harder it became ; in short, 
that I excited in it the after-pains just as we excite them 
by frictions on the hypogastrium after the child's birth. 
I therefore inferred that the proper way of proceeding 
would be to let it rest, and as soon as the relaxation of 
the organ should be complete, to endeavour to inder/t its 
fundus, like the bottom of a bottle, and then carry it 
upwards. I found, upon observing it, that the womb 
repeatedly expanded or relaxed, and then contracted 
again. Taking therefore the moment of the completest 
relaxation, I indented the fundus with one finger, and as 
it became more and more concave, I applied each of the 
fingers in succession, until I found that its further pro- 
gress was impeded by the os uteri, which, although it 
was completely inverted, yet resisted for some time the 
attempt at reposition. By a resolute perseverance I 
finally had the pleasure to overcome the resistance, and 
the peritoneal surface of the fundus was pushed upwards 
beyond its os uteri, and at last the womb was found to 
be completely restored to its natural position, but still 
containing my hand, which was now up as high as a 
little above the umbilicus. As no contraction came on 
immediately, I retained possession of the cavity of the 
womb, which I gently excited by moving my fingers 
within it, and finally a contraction came on which I 
suffered to push my hand out into the vagina. Upon 



INVERSION OF THE WOMB. 343 

withdrawing the right hand, I felt with the other the 
womb very firmly contracted in the lower belly, and 
enjoyed the satisfaction of complete success in this dis- 
tressing case. 

I have said nothing of the brandy and volatile alkali 
that was given to the woman to keep her from 
dying. She took a very large quantity of these articles, 
besides laudanum, before I left her, which I was obliged 
to do in order to attend to another patient, and I feel 
under great obligations to my friend Dr George Fox, 
who came at my request and took charge of Mrs S. for 
the remainder of the time that she continued ill. Her 
situation when I gave her up to his care was nearly 
desperate, from anemia; nevertheless, by the adminis- 
tration of proper restoratives and the judicious exhibition 
of stimulants, during several hours, she rallied, and, 
in no very long time, recovered a good share of health. 

From that period she has never been quite regular as 
to the catamenia, which have appeared at uncertain 
periods, and less abundantly than before her dreadful 
accident. 

Mrs S. is again pregnant, and is now advanced to 
between the fifth and sixth months, more than Ciwe years 
having elapsed since the birth of the last child.* 

I cannot refrain from mentioning here the case 
related by Mr Charles White, of Manchester, in which 
he succeeded in restoring an inverted womb to its natu- 
ral state by compressing it, and then pushing it up. In 
his case I am not very sure that the inversion was com- 
plete, since, although he represents the inverted uterus 
to have been as large as a child's head, it was never 
expelled through the external organs, and it is improba- 
ble that if fully inverted it could be retained in the 
excavation. Mr W. regards his method as of the very 
highest importance, and thinks he should never have suc- 
ceeded but for the compression of the v^^omb in the hand. 

* Since the above paragraph was written, Mrs S. has been 
safely deUvered of a healthy child by my friend Dr Bache. It 
is worthy of remark that the placenta was adherent in this case 
also; p.nd Dr B. was not able to effect the delivery of the after- 
birth until he had separated it from the womb by the introduction 
of the hand into its cavity. 



344 INVERSION OF THE WOMB. 

I am ready to admit that it might happen that a tonic 
contraction of an inverted uterus should come on at once, 
and last so long as to prevent the employment of the 
plan that I suggest ; but 1 think it probable that it would 
always be practicable to return it, in any case where it 
had not been inverted more than four or five hours, by 
waiting for the moment of its greatest relaxation, and 
then first indenting the fundus, and afterwards pushing 
it steadily upwards through the os uteri, and so into the 
abdomen again. 

I have recently seen a lady whose womb was inverted 
about two years ago, at her confinement. I am informed 
that she then had a very profuse hemorrhage, and was 
thought to be in extreme danger. She gradually got 
better, however, but remained subject to frequent attacks 
of hemorrhage, by which her strength became greatly 
reduced. At length a physician whom she called in 
made an examination, and found the womb inverted. In 
this case the womb hangs into the vagina, and is, I think, 
turned completely inside out; it is not much larger than 
the healthy non-gravid womb — does not appear to be 
very sensible on pressure, but bleeds very easily. By 
careful regulation of the diet, strict attention to her 
bowels, and the use of astringent injections, under the 
care of her physician, Dr Moehring, the hemorrhagic 
tendencies have of late been happily counteracted and 
she is acquiring a more decided state of health. She 
goes freely now about the house, and even about the 
city. This I regard as a very consolatory case, as it 
furnishes ground to hope for the escape of our patients 
with life, even where the inversion is incurable. 

It has been stated that when the womb is only half 
inverted, the woman is liable to greater pain and danger 
than where it is turned completely inside out, in conse- 
quence of the strangulation of the part that is griped by 
the OS uteri. It is thought by some persons good prac- 
tice in such cases to make the inversion complete. I 
am unable to speak of this point from any experimental 
knov; ledge that I possess, yet I feel ready to admit that 
the probabilities of recovery would be greater with a 
complete than with an incomplete inversion. 



CHAPTER XVIII. 



PUERPERAL FEVER. 



Lying-in women are very liable to attacks of inflamma- 
tion of the peritoneum, or lining membrane of the abdo- 
men ; and such is the tendency of this inflammation to 
spread like an erysipelas over the whole surface of the pe- 
ritoneum, that it not unfrequently extends over the entire 
internal paries of the belly, producing so violent a fever 
and so considerable a disturbance of the functions of im- 
portant viscera invested by the peritoneum, as to prove 
fatal in a great many instances. 

Seeing that the superficies of the peritoneum is 
equal, probably, to ten or twelve feet, we should have 
abundant reason to dread so extensive an inflammation, 
from the constitutional irritation which it alone would 
produce ; but when, in addition to that consideration, we 
take into view the great effusions which may ensue, the 
suppurations, the interruption of the intestinal functions, 
the depravation of the actions of the liver, &c., which 
are occasioned by it, we have still greater reason to de- 
precate its attack, and to seek for the justest views of 
its nature, and of the remedies most appropriate for its 
cure. 

Peritoneal inflammation occurs more frequently in 
women in child bed than in any other class of persons. 
It generally follows labour within from two to four days; 
but it may occur either earlier or later ; sometimes, 
making its attack even before labour begins, and being 



346 PUERPERAL FEVER. 

deferred in other cases until the third week of the con- 
finement, or even later. 

The subject is predisposed to it, probably from 
various causes, among which are the severe pressure 
which occurs during the expulsive efforts for delivery ; 
the extreme distension which the membrane has suffered 
in the last weeks of gestation ; the violent excitation of 
the womb itself by the labour pains ; and lastly, the com- 
plete relaxation of the membrane and its adjacent tissues, 
following the birth of the child. 

The pressure produced by the bearing down of the 
woman in labour is often so great and so long continued, 
that an effect analogous to contusion cannot fail, in many 
instances, of taking place, since the whole muscular 
power of the abdominal muscles is expended in propelling 
the uteri fundus towards the os uteri. Such contusion 
of contiguous portions of the peritoneum would be readily 
followed by inflammation, and the more readily in pro- 
portion as these efforts might have been greater, or longer 
continued, and, in fact, we do find that bad labours are 
more apt to be followed by peritoneal fevers than easy 
or good ones. 

The peritoneal coat of the womb is greatly expanded 
or stretched in the last stages of pregnancy. The broad 
ligaments are drawn up on the sides of the uterus to a 
considerable height, while the portion of the membrane 
that lines the front and sides of the belly, is also put 
greatly on the stretch. This tension could not but increase 
its natural proneness to take on inflammatory action, if 
exciting causes should be applied after delivery. 

The womb itself is left after labour with so great a 
disposition to inflame, that very slight occasional causes 
suffice to set that disorder on foot in the structure of the 
womb itself, which may serve as the radiating point for a 
peritonitis that shall involve the whole extent of the serous 
tissue of the belly. It is very common in the post 
mortem examination of puerperal fever cases, to find the 
results of inflammation not only on the serous coat of the 
uterus, but also in its proper structure, as well as in that of 
the ovaries. These results are evinced in the effused 
pus found in the substance of those organs, and in their 
veins. 



PUERPERAL PEVER. 847 

The relaxation of the peritoneal membrane that follows 
delivery, and the reduction of the womb to a small size, 
is beyond doubt one of tlie most fruitful sources of in- 
flammation of the membrane. The sanguine determina-* 
tions are greatly affected by the relaxation of the muscles 
and integuments of the belly, consequent upon the com- 
plete contraction of the womb. It will not be denied 
that the blood that escapes from the aorta by the coeliac 
and the mesenteries, as well as that which passes along 
the spermatic and uterine arteries, will meet less resist- 
ance to its flow where the tegumentary and muscular 
tissues of the abdomen are quite flaccid and devoid of 
tone, as after child birih, than where they are in a state 
of great tension, as before labour commences ; but if the 
blood of the chylopoietic organs reaches their capillary 
vessels with less resistance or greater facility, then, 
those organs will be more liable to sanguine affluxions, 
engorgements, and irritation, on account of this very 
weakness and relaxation. 

A similar liability exists for patients who have been 
tapped for ascites. Such patients are extremely apt to 
be seized with peritonitis, which, however it may be in 
a measure considered as a consequence of the wound 
made by the trocar, is, nevertheless, more apt to ensue 
in such as are not carefully bandaged after the tapping, 
than in those who procure a proper degree of compression 
by a bandage which serves as a substitute for the tone, 
or rather resistance of the muscles and integuments, 
which is almost wliolly abolished, at least for some hours 
or days, by the drawing off of the water from the perito- 
neal sac, as it also is after delivery. 

Taking this view of tlie tendency which the relaxa- 
tion,' or want of tone or support, occasioned by delivery, 
gives to attacks of peritonitis, 1 find it not surprising that 
those women who get up too soon, or sit up too long, 
should suffer more readily than those who preserve a 
horizontal posture for several days after childbirth. A 
woman who gets up very soon is much exposed to the 
dangers of flooding from the sudden engorgement of the 
uterine vessels, occasioned by a vertical position. The 
hemorrhage that often comes on in consequence of this 



348 PUERPERAL FEVER. 

imprudence is an effort of nature to relieve the engorge- 
ment of the abdominal and uterine blood-vessels, produced 
by a too early getting up ; but, where this relief is not 
procured by evacuation of the engorged vessels, inflam- 
matory excitement may supervene, especially if the 
centripetal determination of the blood is augmented or 
reinforced by the occurrence of chills, to which the woman 
is more obnoxious out of bed than in it. Not a few of 
the cases of peritoneal inflammation that have come 
under my notice were clearly attributable to the impru- 
dence of the patient in getting too soon out of bed. 
Such an act of imprudence ought not to be permitted. 

Vascular excitement, from whatever cause produced, 
may become fixed upon the serous membrane of the 
belly as an inflammation possessing all the dangerous 
characteristics of child bed fever ; a common milk fever, 
therefore, ought not to be permitted to become very vio- 
lent, lest it might produce tlie result just mentioned. It 
should be fully reduced by venesection and cooling pur- 
gatives, and above all, by a strict observance of the hori- 
zontal position. Fever of any kind coming on soon after 
delivery, includes at least a risk of an attack of perito- 
nitis. 

Improper diet, and whatever might occasion indiges- 
tion, should be carefully avoided, lest the intestinal irri- 
tation, if severe, should become peritonitis in one 
predisposed that way. I speak upon this point from 
my own observation, having recently seen two women, 
both of whom had peritonitis from indigestion occasioned 
by the use of a kind of food which is very generally 
given to lying-in women. Great care should be taken 
to avoid all indigestible kinds of food 

Costiveness, a very common complaint towards* the 
close of pregnancy, should be obviated by the administra- 
tion of gentle aperients or enemata. An overloaded state 
of the bowels might very reasonably be supposed suffi- 
cient to excite irritation in the abdomen, which, in indi- 
viduals predisposed to peritoneal inflammation, would 
become fixed at last upon the serous surface. 

Suppression of urine, an occurrence frequently met 
with in obstetric practice, should be carefully watched, 



PUERPERAL FEVER. 349 

since an undue degree of distension of the bladder can 
scarcely take place without endangerinp: the life of the 
lying-in woman, from the tendency which accompanies it, 
to excite the first movements of peritoneal fever. It should 
always be regarded as a part of the duty of the medical 
attendant, to inquire into the state of the bladder ; and 
it is far better to resort at once to the catheter for relief, 
where there is any reason to suspect an accumulation of 
water, than to confide in the various diuretic drinks, or 
even to the enema, which, although less disagreeable, 
are far less certain remedies than the catheter. It is 
scarcely ever proper to defer a recommendation of the use 
of the catheter, where many hours have elapsed after de- 
livery, without an urinary evacuation, even if the pa- 
tient complains of no pain. I have observed, in some 
instances, a very great collection to be unattended with 
decided pain. 

It is highly important to pay a strict attention to the 
after-pains, of which puerperal women so commonly 
complain. If they go off perfecily — leaving intervals 
between the contractions ; and especially if, in those in- 
tervals, there is no soreness of the hypogastric and iliac 
regions, upon pressure made thereon with the hand, they 
are of little consequence — but when they do not leave 
the patient with good intervals of freedom from pain, 
they should be held suspected, and quelled by anodyne 
doses, by enemata, and even by the use of the lancet. 
Obstinate after-pains — particularly those which continue 
for several days, not very rarely serve as the masks of a 
peritonitis, which is the more dangerous, from having, 
by its insidious approach and attack, beguiled the un- 
wary practitioner, until his means of resistance, which, 
at the beginning, might have proved completely ade- 
quate — have, by procrastination, lost all efficacy. In 
urging the attention of the practitioner to this point, I 
by no means wish to be understood as asserting that it is 
always easy to discriminate between after-pains and the 
early stages of a peritoneal fever — on the contrary, it is 
on account of the difficulty of making such a diagnosis, 
that it becomes important to attend sedulously to the 
symptoms. Those peritoneal fevers, and they are not 
2 E 



350 PUERPERAL FEVER. 

few, which are connected with an imflaramation of the 
uterine sinuses, are the most dangerous — and I have no 
doubt that some of the very distressing after-pains which 
we meet with in practice, but which we subdue, are oc- 
casioned by a high degree of inflammatory irritation of 
the uterine texture, whose course being happily checked, 
leaves us without any fatal or post-mortem evidences of 
its existence. I am free to say, that I have often been very 
much embarrassed to decide whether ray suffering pa- 
tient was affected with mere spasmodic contractions of 
the womb, or whether she laboured in addition to such 
spasm, under an inflammation of that organ. I have 
many times abstracted blood freely for the relief of the 
symptoms, and, obtaining complete relief, have remained 
still uncertain whether my remedy had put a stop to 
spasm merely, or whether it had overcome an incipient 
inflammatory excitement of the uterus and ovaria, by 
which the patient was exposed to the greatest dangers 
of peritoneal fever. I will beg leave to repeat, ihat af- 
ter-pains ought to be carefully watched, and when ac- 
companied with an excited circulation and tenderness of 
the hypogastric region, should be met by free depletion 
as the chief of remedies. There are other remedial 
measures that need not be again spoken of here. 

Puerperal fever, generally, is ushered in with a chilly 
fit, more or less considerable, and of various duration, 
but ordinarily not very long; the pain which accompa- 
nies it, commences in the hypogastric or one of the iliac 
regions, and increases and extends its limits as the fe- 
ver augments. The fever is occasionally very high — 
while the pain is not very intense, and in the epidemic 
cases of the malady, some women are met with who do 
not even complain of pain at all, notwithstanding the 
most active inflammatory changes are going on in the 
abdomen, as disclosed by post-mortem examinations. 

The vascular system reacts with the greatest prompti- 
tude, when moved by peritoneal inflammation ; the pulse 
acquires a frequency, rarely less than J 20, and com- 
monly of 140, strokes per minute. In the early stages 
of this vascular re-action the artery is full, strong, and 
possessing tlie characters of the synochus fortis pulse : 



PUERPERAL FEVER. 351 

but this high grade of energy is soon passed ; the pulse 
acquires greater frequency with diminished hardness 
and volume. If tlie inflammation, like a rushing fire, 
seizes on the whole serous membrane, the constitutional 
irritation which is produced by it, rapidly exhausts the 
vital powers, and the patient sinks very much in the way 
that those perish who have suffered extensive laceration 
or fatal injuries of some great articulation. All remedies 
are useless when the whole nervous and vascular sys- 
tems have suffered a shock sufficient to overthrow their 
functional power, and the patient sinks rapidly, in 
despite of tlie cordials, the opiates, the counter-irritants, 
and other appliances which are, in a sort of desperation, 
resorted to by the medical attendant. A child-bed fever 
should be cured very soon, or it will scarcely be cured 
at all ; and why should we expect to cure a peritonitis 
which we have reason to suppose connected with an in- 
flammation of the whole serous membrane? If a small 
part of that membrane only be affected, as is the case 
in the commencement, we may hopefully endeavour to ef- 
fect a resolution of the inflammation by bleeding, &c., but 
when it has had time to be wholly involved in inflam- 
mation, I think any experienced practitioner will agree 
with me in expecting the inflammation to result not in 
resolution but in effusion ; which effusion ends in death 
very commonly. 

Such is the rapidity with which the peritoneum becomes 
universally involved in inflammation, that not a few per- 
sons have, in their writings, brought into some discredit 
the use of the lancet as a remedy, their own judgments 
having been staggered by the vain employment of the re- 
medy in stages wherein the loss of blood could not do 
good, and seemed only to precipitate the fatal result. A 
woman, for example, may be attacked with the disease af- 
ter the physician has seen her in the evening ; the nurse, 
who supposes that all pain in the abdomen is after-pain, 
and all fever, milk fever, does not become alarmed, and 
when the physician arrives, he finds the patient already 
far advanced in, or at least on the point of tliose effu- 
sions into the peritoneal sac, which, while they put an 



352 PUERPERAL FEVER. 

end to the pain, also seal the fate of the unhappy mother. 
Such events have occurred under my own practice. 

I would earnestly endeavour to impress upon the mind 
of the student of medicine, the vital importance of great 
promptitude in his attention to the earliest signs of this 
dreadful malady. I would convince him that the prin- 
cipal feature in the disease called child-bed fever, is pe- 
ritonitis — that the inflammation is so acute, and the tissue 
in which it is seated so inflammatory, that the malady is 
capable of hurrying through its curable stages more ra- 
pidly than even the redoubtable croup, and what is of 
still greater moment, that it is in the incipient stages 
nearly as curable as croup, and that the remedy, or I 
might say the cure, consists in the bold and judicious 
employment of venesection. Let me ask, what can be 
the value of any remedy, short of venesection, in a ma- 
lady like this — which presents a case of pure inflamma- 
tion — occupying, or making haste to occupy^ not a few 
square inches, but many square feet of a membrane that 
serves as the investment of the most important organs. 
In what light, save as mere juvantia, can any reasonable 
man regard the few grains of calomel and opium, or 
ipecacuanha, or the few drops of spirits of turpentine, 
which are by some persons given as remedies for such 
wide extended mischief! Nothing but abstractions of 
blood can have an immediate and potent influence on 
the circulation, and reduce the momentum of the blood 
to such a degree of moderation, as may consist with a 
resolution of the inflammation. Peritonitis always has 
one or the ather of these two terminations— resolution 
or eflJ'usion ; with the former the patient recovers, with 
the latter she dies. Dr Gordon tells us, that it is not 
merely bleeding the patient that will save her. Slie 
must be bled copiously — so copiously as to give to the 
disease a definitive check. He tells us that where the 
woman is bled timidly, no available impression is made, 
that the disease advances and soon becomes indomita- 
ble. Twenty-five or thirty ounces drawn from the arm, 
early in the attack, rarely fails to make so powerful an 
impression on the disorder, that the juvantia — such as 



PUERPERAL FEVER. 353 

calomel, opium, &c., hardly fail to effect the remainder 
of the cure. 

All the experience I liave had in regard to the course 
and treatment of this malady, leads me to concur fully with 
the instructions of Dr Gordon on the subject, and it is al- 
ways with regret that I reflect on tlie published opinions 
of Goocli and otliers, who appear to bring into distrust the 
best of all possible resources for tlie management of this 
violent disease. I am almost ready to say, that the case 
of peritonitis which will not admit of the use of venesec- 
tion is hopeless — that all other medical measures are 
trivial when compared with its prompt and salutary in- 
fluences ; and also, that I can with difficulty conceive of 
a case of the disease in which the lancet would be inad- 
missible in every period of its origin and progress ; 
there should be found some point of time in which it 
could be resorted to. While I profess in the strongest 
terms to confide in the lancet as the first and chief reme- 
dy, I would not pretermit any mention of leeches, which, 
as a secondary and subservient prescription, will be found 
of the greatest utility in the management of the cases. 
They should be freely employed, by scattering them 
over the parts of the abdomen most affected with pain 
and soreness. Cataplasms and warm fomentations may 
be advantageously used after the removal of the leeches, 
and the bowels should be well evacuated by means of ene- 
iTiata, or by doses of calomel aud castor oil, to be follow- 
ed, after the operation, by doses of calomel and opium, 
or calomel and Dover's powder, with warm mucilagi- 
nous drinks. These serve, after the evacuation of the 
bowels, to promote perspiration, which, when properly 
excited or produced, counteracts, in an eminently useful 
manner, the internal disorders of the circulation. 

So great is the influence exerted by peritonitis upon 
the sanguiferous apparatus, that even where we succeed 
in effecting a most hopeful and flattering reduction of 
the pulse by a first bleeding, the blood vessels soon come 
to be excited again, and the torrent of the circulation re- 
sumes its violence in an hour, or even less. Such a re- 
action should be met and quelled by repetition of the 
bleeding again and again, until it is deemed no longer 

2 E* 



354 PUERPERAL TE^T-R. 

needful or safe to abstract blood. "When the power of 
the hearf s contraction is sufficiently abated to cause it 
to propel its blood into the aorta with a gentler and more 
healthful momentum, the capillaries, which are the seats 
of the inflammation, will become capable of throwing 
off the masses of blood which have oppressed them, 
and the constitutional disorders that arose from, and then 
progressed, pari passu with the peritonic irritation, wili 
subside as it subsides, and disappear with its removal. 

There are no considerations relative to the treatment 
of puerperal fever, that I regard as claimincr to be com- 
pared in importance with those that concern the use of 
blood-letting ; yet, as it is not possible for me to give, in 
this small work, my views, and the reasons for them, at 
full length, I shall say no more here upon the use of 
the principal remedy — but I shall go now to the explana- 
tion of some circumstances which I think deserving of 
the reflections of the student, and the most careful ob- 
servation of the practitioner. 

One of the early symptoms of a peritonitis is flatu- 
lent distention of the bowels, or tympanitis. It is a 
source of infinite mischief, and very difficult of removal. 
Tympanitis consists in inflation of the intestinal tube, 
and not in the inflation of the peritoneal sac, as some 
are inclined to suppose. The air of which the swelling 
is composed, is extricated from the food or drinks of the 
patient while in a state of fermentation — a fermentation 
that could not exist except where the digestive force is 
impaired, but which force is necessarily impaired where 
the pulse is at 130 or 140, and where the alimenta- 
ry tube is invested by a peritoneal coat — already in prey 
to an active inflammatory disease. But not only is the 
digestive force greatly impaired, — the alimentary tube, 
whose outer investment consists of peritoneum, refuses 
to contract : the gases that are developed, simply distend 
portions of the tube, whose muscular fibres, like all 
muscles whose integuments are inflamed, either refuse 
to act, or act so feebly as to sufi^er the canal to be inflated, 
or completely blown up, like a bladder, with the gases of 
the bowels. In a puerperal woman with peritoneal fever, 
it is not uncommon to find the abdomen as larg-e as 



PUERPERAL FEVER. 355 

at the seventh or eighth month of gestation, from in- 
flation of the bowels. They become so tense with the 
tympany, as to resound upon percussion like a drum. 
They in this state prevent, in a measure, tlie play of the 
diaphragm, whose concavity is at the same time lined 
with an inflamed peritoneum, that in a degree cripples its 
power, and the patient soon begins, on these accounts, to 
have dyspenoea, with panting respiration, while the capil- 
lary system of the whole intestinal canal, which is put 
upon the extremest stretch and tension, grows rapidly less 
and less able to get rid of its load of blood by any other 
process than effusion. I have seen some women dying 
with child-bed fever, who sunk rapidly, and evidently 
more rapidly, from the great degree of irritation occa- 
sioned by the tympanitic distention of the bowels — their 
respiration being not dissimilar from that occasioned by 
hydrothorax. 

In all febrile affections, a tympanitic distention of the 
alimentary canal is greatly to be deprecated, and in none 
more than that of which we are speaking. In peritoni- 
tis it adds new dangers to those which are already so 
imminent, and should be carefully obviated by proper 
remedies. Now, it may be said that there could be no 
tympanitis in a case in which the peristaltic fibres of the 
bowels should continue in the regular exercise of their 
functions : but where a tract of the jejunum or colon is 
fully inflated, there is for the time being a total suspension 
of the peristaltic movement of the muscular fibres of the 
tube ; they being in a quasi state of paralysis, or inaction 
at least, so as to permit the extricated gases of the canal 
to inflate it. In order to obviate this evil, we are obliged 
to make use of aperient medicines, or even purgative 
doses, to stimulate the peristaltic fibres into a degree of 
activity sufficiently great to enable them to exclude or 
pass onwards the gases with which they are distended. 
For this end calomel and opium, followed by moderate 
doses of oil, are highly appropriate — or we can rely on 
doses of infusum rhei, with addition of small portions 
of potash or soda — or magnesia with mintwater — or a 
solution of manna, with addition of magnesia and oil of 
anise seed, 



356 PUERPERAL FEVER. 

I have on many occasions found the introduction of a 
catheter into the rectum capable of drawing off the 
whole of the air of the tympany. Very recently a dis- 
tressing tension of the abdomen, after delivery by the 
Cesarian operation, was suddenly and completely re- 
lieved by the introduction of a female catheter a few 
inches-into the rectum. The bowel had not power to 
overcome the sphinctorian contraction, and the patient 
was inflated in consequence ; the catheter, when passed 
above the spincter, permitted the gas to rush out of the 
tube with a hissing noise. It is an excellent resource, 
unattended with pain or the least inconvenience. 

I am far from desiring to be considered as in favour of 
very active purging as a remedy in peritonitis. It would 
be obviously improper to enter upon the management of a 
case of the malady without procuring a sufficient evacua- 
tion of the faeculencies that are generally accumulated in 
the bowels of lying-in women : that should be always 
attended to, and when the physician is satisfied that they 
have been removed, he should abstain, as a general rule, 
from the use of strong purges ; but if the tympanitic 
state of the patient requires it, he should by no means 
withhold the aperient medicines which have been re- 
commended. 

It is frequently found, that, even in those cases where 
we feel assured the peritonitis has received, by the lancet 
and other means, an effectual check ; where the pain is 
all gone, and even the soreness removed, the patient con- 
tinues to liave fever, which may last many days. Under 
these circumstances the use of James's powder, or the 
golden sulphur of antimony, combined with nilre and 
calomel, is of the greatest value. These medicines very 
generally give rise to copious diaphoresis, wliich may 
be maintained by draughts of warm herb tea, such as 
the balm, or sage, or by copious draughts of barley-wa- 
ter, and a careful adjustment of the bed-clothes to the 
condition or circumstances of the patient. 

During the whole period characterised by active in- 
flammatory symptoms, the diet ought to consist of bar- 
ley-water, very thin gruel, or arrow-root, and such like 



PUERPERAL FEVER. 357 

articles. A greater degree of indulgence may be al- 
lowed after the fever has quite disappeared. 

Rest, in a recumbent posture, is one of the essentials 
of the successful management of the case. The nurses 
should be forbidden to raise up the patient even in bed — 
for if an early getting up from bed may serve as the ex- 
citing cause of the disorder, it would surely be very 
dangerous to get into a vertical or sitting posture while 
the inflammation is in full activity. 

For the most part, the lacteal glands do not secrete 
much milk in women in peritoneal fevers. It is always 
a salutary sign w'hen the breast continues to be full under 
this disorder. 

The lochial discharges are also very much diminished, 
and sometimes wholly disappear during the greatest in- 
tensity of the malady. Tepid vaginal injections of mu- 
cilage of flax seed, or of milk and water, may be with 
prospect of benefit made use of, where the patient can bear 
so much handling. The discharges which are checked 
or suspended during the onset and greatest violence of 
the complaint, reappear upon its decline or cessation. 

Blisters are held as favourite applications in puerpe- 
ral fever. I doubt not they may in proper circumstances 
contribute greatly to the safer and more speedy cure of 
the inflammation ; but I think I have seen blisters ap- 
plied too soon in some cases, and I have reason to sup- 
pose, that if not properly timed, they are capable of 
adding to, instead of diminishing, the constitutional dis- 
turbance, already too great. If applied very early they 
increase the fever and irritation, and continue to be in 
the way of other more useful remedies ; they confound 
the diagnosis — which should be often repeated — by ren- 
dering the practitioner unable to discriminate between 
the pain produced by the cantharides and that arising 
from the internal disorder, which is greatly to be de- 
precated, since his opinion and practice in the case 
should be very much governed by the degree of pain — 
as it is in pleuritis. A blister, applied after a due reduc- 
tion of the force of the circulation, and an ascertained 
diminution of the pain and soreness of the belly, may 
happily bring about a resolution in cases which, but for 



358 PUERPERAL FEVER. 

the well-limed prescription of such a remedy, might 
end in a fatal effu.-ion. 

I do not think that the malady is at all disposed to re- 
sult in gangrene or mortification. The affected parts are 
too important and too numerous to be the subjects of 
such terrain itions ; the patient dies before they can be 
effected. The adhesive inflammation is found to have 
exerted its salutary power in some of the samples; but 
the adhesions are very partial, the far larger portion of 
the membrane having poured out vast quantities of a 
sero-puriform liquid, containing a great abundance of 
flaky matter, which appears to consist of coagulated 
albumen, and which is found floating in the fluid con- 
tained in the peritoneum, or adhering like a croup mem- 
brane to the peritoneal surface of tlie bowels, liver, 
stomach, &c. 

A woman who labours under an acute peritoneal fever, 
is generally found lying on the back, with the knees 
drawn up ; the hands are rarely to be seen crossed on 
the abdomen — they are laid by her side, across the breast, 
or they are employed in holding up the bed-clothes, whose 
weight is apt to give pain if pressed on the belly. Every 
attempt to put down the legs, and to draw them up again, 
or to rotate the legs, is productivenf pain, because there 
is implied in such motions a contraction of the psoae and 
illiacae internae muscles, as well as the rectus and oblique 
muscles of the belly ; but the contraction of any one of 
these muscles occasions a change of relation of parts of 
the inflamed peritoneum. The woman therefore moves 
unwillingly. She lies remarkably still, and if afl'ected 
with jactitation and resdessness, she expresses it only 
by flinging her arms about, and by frequent rotations of 
the head. She always endeavours to keep the abdomen 
and lower limbs quiet; for she knows that every move- 
ment of them is distressingly painful. Hence the mere 
decubitus is important as a diagnostic sign. 

To find an improvement in the patient's ability to move 
herself, with a corresponding improvement in the circu- 
lation, is of the most favourable augury; but to observe 
the pulse increasing in frequency while it also becomes 
more feeble, with diminished heat of the members and 
augmented heat of the body, to discover a disposition to 



' PUERPERAL FEVER. 359 

singultus, with an eructation of fluids into the mouth, 
an anxious expression of countenance, high and fre- 
quent respiration, with increased ability to move the 
legs, and diminished pain on pressure, are all indicative of 
the cessation of inflammation of the peritoneum ; but it 
has ceased not by resolution, or a return to health — it has 
come to one of its natural terms in eff'tision. The in- 
flammation is at an end, and the patient begins to die. 
It would seem that the forces of the living economy 
have exhausted themselves in the struggle with a ma- 
lady, which, though they conquer it at last, yet are 
themselves destroyed in the moment of victory. There 
soon comes on a vomiting, or rather a violent eructation 
or gurgitation of dark-looking fluid ; the patient mutters, 
she picks the bed-clothes, she clutches at muscae volitan- 
tes, the diaphragm labours to carry on in vain the work of 
respiration, the hands and feet acquire a livid hue, and 
are clammy, the pulse becomes a thread, it ceases in the 
wrists, and she dies, probably in the act of regurgitating 
from the stomach the last draughts which the anxious 
hand of friendship or love has tendered as a solace or a 
hope. It is altogether a most melancholy scene, for, 
connected with all the moral distress which such a fatali- 
ty lavishes on relatives and friends, there is generally a 
sharper pang for the hapless infant, which, deprived, at 
the moment of opening its eyes on the great theatre of 
the world, of the needful help of its mother, is destined 
to bear for years the bitter fruits of her death. There is 
scarcely a case of disease terminating in the decease of 
the patient which produces such a general sympathy as 
this, and indeed all those which occasion the loss of pa- 
tients in child-bed. 

I am very sensible that I have made but a slight 
sketch of puerperal fever — it is a subject that could be 
better discussed in a volume than in a few pages, but I 
preferred saying a few words upon the subject, even at 
the risk of making a very meagre article, if I could, by 
means of it, bear my testimony against every doctrine 
which shall teach that this most acute, extensive and 
dangerous inflammation is to be combatted by any means 
short of the most signal and active of those which are 
called antiphlogistic. 



CHAPTER XIX 



OF ATRESIA. 



I AM desirous of recording the few remarks that will 
be found under this title, on account of their intrinsic 
interest. 

A lady, from a distant part of the country, came to 
the city last spring (1837), in order to consult Dr 
Randolph, who was good enough to invite me to see 
the patient with him. Her story was as follows : More 
than two , years have elapsed since she gave birth to a 
healthy child ; ihe labour was extremely rapid ; inso- 
much, indeed, that the infant was born before the phy- 
sician could reach the house. The after-birth did not 
come away for an hour, during which time there was 
flooding. It was at length removed by force. The 
lady became very weak. In a few days she was attacked 
with inflammation of the vagina, accompanied with 
enormous discharges of matter, and great thick pieces 
of flesh, to use her own account. She was never ex- 
amined by her physician, who, however, directed washes, 
injections, &;c. &c. After a long and exhausting hec- 
tic, attended with extreme emaciation, her discharges 
grew less copious, and she gradually, at the end 
of some months, got well. There was, however, 
no vagina, not even a cul de sac ; there was simply 
the genital fissure. Of course, no catamenia could ap- 
pear ; but, after several months of good health, she be- 



OF ATRESIA. ^61 

gan to complain of pain or misery in the hypogastric 
and pelvic regions. The pains recurred with periods 
of a month, and having at length become intolerable, 
she found her health declining, and came, as before said, 
to consult that able and eminent surgeon, Dr Randolph. 

There was a tumor in the hypogastrium, which 
reached half-way up to the navel ; it was of a firm and 
resisting feel, not unlike a contracted womb soon after 
delivery. As there was no vagina, the finger was passed 
into the rectum, where it came in contact with the same 
tumor, which seemed to occupy the excavation as 
it is occupied by a child's head, filling the cavity en- 
tirely. Upon separating the labia, there was nothing 
but the genital fissure ; there was no way for a common 
probe to pass upwards. A sound was introduced into 
the bladder, and retained there until a finger was also in- 
troduced into the rectum : the only texture that sepa- 
rated the finger and the sound seemed to be, upon care- 
ful examination, the walls of the ur^eihra and the coat of 
the bowel ; there was no vagina to be felt. Hence 
Dr Randolph and I agreed in opinion, that the vagina 
had been wholly destroyed by the sloughing process 
which took place shortly after her confinement. We 
entertained no doubt as to the nature of the tumor that 
occupied the pelvis and lower part of the abdomen : it 
was the womb hermetically sealed, and retaining in its 
cavity the accumulated menstruations of nearly two en- 
tire years. 

After much diligent search, we were unable to dis- 
cover the cervix, or os uteri ; but we supposed they 
might possibly be turned upwards towards the top of 
the pubis, so as to elude any investigation made through 
the rectum alone, the only possible way of making re- 
search. No vestige of a vagina was discoverable by the 
taxis ; nevertheless, supposing it possible that the whole 
tube might not have been destroyed, and that possibly its 
upper extremity might be reached by the bistoury, Dr 
Randolph operated with a view to make an artificial va- 
gina, and haply to discover the remainder, if any, of the 
original one. 

Introducing a strong metal staflf, slightly curved, into 
2f 



362 OF ATRESIA. 

the bladder, he took his seat in front of the patient, who 
laid on her back, with the knees drawn up and separated. 
I held the staff firmly, while with the fore finger of his left 
hand, in the rectum, to serve as a guide, he dissected, by- 
horizontal strokes of the bistoury, betwixt the rectum and 
urethra, and carried his incisions up very nearly to the 
substance of the womb itself, without having wounded 
either the rectum or the urethra : when he had com- 
pleted his incisions, the whole finger could be passed 
upwards to the bottom of the cul de sac he had formed 
by so skilful and accurate a use of the bistoury. 

In consequence of our uncertainty relative to the 
situation of the os uteri, and from his having successfully 
removed so considerable a portion of the barrier which 
opposed the escape of the contents of the uterus, Dr R. 
suspended his operation at this point. 

It was resolved to keep the passage open by the use 
of a bougie, made as light as possible, and of a size suf- 
ficiently large ; the bougie was made of gilt silver, 
about four inches in length, and as large as the tliumb, 
its weight not more than two drachms. We indulged a 
hope that by using this bougie a few months, the pro- 
gress of the case would be such as to bring the os uteri 
to the extremity of the instrument, by means of the in- 
creasing expansion of the uterine globe, and that the 
contents of the womb would discharge themselves into 
the artificial vagina, or that they might be discharged by 
a future incision. The lady returned to her own coun- 
try, and after an absence of three months came back to 
the city, still suffering under the same misery, with an in- 
creased magnitude of the uterus, but without having had 
any discharge from the vagina. She had constantly worn 
the bougie. Upon examination, we found that the vagina 
was now covered by a smooth surface, resembling a 
mucous membrane ; the upper end of the bougie, when 
withdrawn, was covered with a sort of muco puru- 
lent matter, tinged with blood. The sufl^erings of the 
patient from the distension of the womb were very 
great, and it was agreed to puncture the organ in order 
to draw off its contents. On the 8lh day of July, 1837, 
Dr Randolph and Dr R. M. Huston, who had been in- 



OF ATRESIA. 363 

vited by us to witness the operation, met me at the 
lodgings of the patient. 

The tumour, felt through the vagina, was hard and re- 
sisting, as an enlarged ovarium ; it was softer and the 
walls thinner when examined through the rectum. At 
Dr Randolph's request I now made use of a curved 
trocar, enclosed in a canula, in order to puncture the 
womb. The trocar was about five inches in length, and 
of the size of a small writing-quill. The patient was 
laid on her back near the edge of the bed ; I introduced 
the forefinger of the left hand into the rectum, and hav- 
ing directed the end of the finger to a part of the tumor 
that felt most yielding, I carried the point of the trocar 
along that finger, and having given it a direction as nearly 
as possible perpendicular to the surface of the tumor, 
pushed it through the resisting tissue until I found it had 
freely entered the cavity ; the trocar was now with- 
drawn, leaving the canula in place. There issued from 
the open end of the tube a dark red viscous substance, 
without odour, of the consistence of meconium, and as 
adhesive as that substance. The puncture was scarcely 
felt. In twenty-four hours, during which the canula 
was permitted to remain in situ, about twenty-five 
ounces of this fluid were discharged ; the uterine tumour 
bad disappeared from the hypogastrium, and the mass, 
as felt in the rectum, greatly reduced in size, and was 
far more moveable. As all the liquid seemed to be now 
evacuated, the canula was withdrawn : no discharge fol- 
lowed its withdrawal. The patient had no symptoms 
attributable to the puncture ; she rapidly recovered her 
strength, and left the city with renovated health, and 
nearly free from the misery which had so long embit- 
tered her existence. In the course of about a month 
after returning to her home, she had a very copious dis- 
charge from the vagina, of a fluid of a consistence similar 
to that which had flowed through the canula, but of a 
whitish colour, after which her health greatly improv- 
ed. I have recently learned that she has not yet men- 
struated. 

Should the womb again become distended, she may 
again be relieved by the trocar. Circumstances alone 



364 OF ATRESIA. 

could determine whether a new puncture should be made 
from the upper end of the vagina or through the rectum, 
as at first. 

We have considered it possible that even a part of the 
womb itself might have sloughed away at the time the 
vagina was destroyed. 



Note.— Dec. 14, 1837. On Tuesday, the 12th inst., the pa- 
tient, while on her way to the city, for the purpose of further ad- 
vice, discharged from the vagina about twenty-five ounces of a 
substance in all respects similar to that which passed off when I 
used the trocar to puncture the womb. The discharge has now 
ceased, and she is quite free from pain, or any inconvenience, or 
disorder of her health. 



CHAPTER XX. 



MORBUS CGERULEUS OF INFANTS. 



I FEEL desirous of recording, in this place, a few ob- 
servations relative to the affection of new born infants, 
usually termed blue disease, and which is well known 
to arise from an incomplete state of the septum of the 
auricles of the heart. 

At the fifth month of gestation, the two auricles con- 
stitute nearly a common cavity, in consequence of the 
septum auricularum being so little developed at that 
early stage of existence. With the progress of the preg- 
nancy, the septum becomes daily more and more com- 
plete, through the sixth, seventh, eighth and ninth months, 
until, at term, the foramen ovale is supposed to be nearly, 
if not wholly, closed up. In many children that at first 
present slight appearances of asphixia, but subsequently 
prove to be very thriving, 1 have supposed the septum 
to have been at birth not sufiicienlly closed, but to have 
been completed within a week or two after birth. Not 
a few cases, however, will be met with in a large practice, 
where the asphixia is followed by the death of the pa- 
tient, within a few days after its first seeing the light. 
These are mostly instances in which the child never 
does acquire a healthy tint of the skin, from its first cry 
until its death. 

It does not follow, that because the foramen ovale is 
open, the patient must always present the evidences of 
2 F* 



366 MORBUS CCERULEUS OF INFANTS. 

an imperfect pulmonary circulation. I have seen several 
instances in which the child was apparently perfect, be- 
ing ruddy, contented and thrifty as could be desired, but 
which, nevertheless proved, after several days, to be 
samples of morbus coeruleus of a fatal kind. It appears 
to me, therefore, that the foramen ovale is, in some, con- 
siderably open, although the subject gives no evidence 
of it by a blue colour of the skin, or any signs of a 
want of oxygenation of the blood. 

If a child be kept very quiet, its wants well under- 
stood and attended to, it is capable of carrying on the 
pulmonary and systemic circulation perfectly well, not- 
withstanding an open foramen ovale ; whereas, if it be 
neglected, or allowed to fall into a great passion and 
violent crying fits, the blood begins to find its way 
through the foramen ovale into the left auricle, to such 
an amount as in a few days to destroy it. 

Without having kept any record, I think I may ven- 
ture to say, that I have seen from twenty-five to thirty 
cases of morbus cceruleus ; cases fully deserving that 
appellation. And that a still greater number of infants 
have fallen under my notice, in which a slight blueness 
about the mouth, and in the hands and feet, have induced 
me to suppose that a part of the blood was still trans- 
ferred from the right auricle directly into the left one, 
but not to such an amount as to produce any serious 
disturbance of the child's health or comfort. The new 
born child can bear, without great difficulty, a degree of 
asphixia which would be highly^distressing, if not fatal, 
for an adult. The blood, with which it has been ena- 
bled to grow and thrive up to the period of its birth, is, 
essentially, a black blood, and the mere fact of the 
establishment of its respiratory in place of the placental 
mode of oxygenation, does not imply any necessity for 
so complete a process of oxygenation as is demanded 
for a more advanced state of its organization and func- 
tions. I am, by the above reasons, induced to believe 
that, in new born children generally, the foramen ovale 
is somewhat open : I do not, in fact, remember to have 
seen a very young subject dissected, in which it was 
not open. 



MORBUS CCERULEUS OF INFANTS. 367 

In those cases, in which a very large part of the blood 
continues to pass through the foramen ovale after birth, 
the child becomes blue, and sleepy, and dull — is af- 
fected with irregular respiration — sometimes breathing 
very slow, and at others very fast, and sooner or later 
is affected with spasms, and even with convulsions, 
which are apt to come on when it cries or is disturbed. 
If left quiet and asleep, the colour soon assumes a more 
favourable appearance, so that hopes of its recovery are 
entertained, until, upon some motion in dressing or nurs- 
ing it, the heart's action again becomes irregular, the lungs 
are engorged, and the blueness becomes more and more 
intense and permanent, until convulsions at length put 
an end to its distress, with its life. 

I had seen many infants perish in this manner, and 
knew of no mode of treatment presenting a reasonable 
prospect of success. About two years ago I, however, 
treated a case successfully, and have since met with 
two other instances, in which the same method was fol- 
lowed by a similar fortunate event. 

The child was three or four days old — a female, which 
had been perfectly well since its birth. I was called to 
see it, and found it blue, gasping for breath, nearly pulse- 
less, and affected with frequent spasms. It had been 
taken out of the mother's room, in order that she might 
not see it die — for to all appearance it was in a dying 
state, and seemed unlikely to live for half an hour. 
Upon judging that all its symptoms depended upon the 
transmission of blood through the septal foramen, I at 
once reflected on the theory of the circulation, advoca- 
ted by Soemmering, and resolved to place the child in 
such a position as would most favour the transit of the 
blood along the iter ad ventriculum, and oppose its 
escape through the foramen ovale. 

Having adjusted some pillows and laid the child upon 
them, on its right side — the body inclined at an angle of 
30 degrees, I ordered the nurse not to move it from 
the position in which I placed it, for many hours. My 
hope was, that by laying the infant on its right side, 
and maintaining the heart in such an attitude, the 
left auricle would be perpendicularly above the right 



368 MORBUS C(ERULEUS OF INFANTS. 

one, and that the effect of gravity alone on the blood 
would gradually operate in such a manner as to allow it 
to flow off into the ventricle, instead of finding its way 
to the systemic auricle. 

Let the student reflect on the probable effect of such 
a position of the heart, continued for some hours, and I 
think he will concur with me in the opinion, that the 
mode of treatment was at least founded upon a rational 
theory, and that is was better than to attempt to relieve 
the patient without any plan or principle for my gui- 
dance. 

The child was left upon its side for six hours ; at the 
end of that time the convulsions had ceased, the healthy 
hue of the skin was restored, and every trace of the as- 
phixia had totally disappeared. The child got perfectly 
well, and is now quite healthy. 

The next case that I saw was a very small child, 
which was feeble at its birth, but did not present any 
appearances of asphixia for several days subsequent to 
its birth. I was called to it in haste, and it was so ill, 
that several persons in the room who were about it after 
my arrival agreed with me that it was dying. I did not 
think it could, at one time, survive for ten minutes — it 
was blue, it gasped, it had no pulse at the wrist, and the 
interval of the respirations was so great that we once 
supposed it had entirely ceased to breathe. I resolved to 
place it upon its right side, as had been done in the first 
case — the pillows being inclined so as to keep it at an 
angle of about 30 degrees to the horizon. It was or- 
dered to be left in that posture for several hours, and as 
there seemed to be a great engorgement of the thoracic 
contents, I requested the nurse to have one American 
leech applied to the region of the heart. My directions 
were very fully complied with, and in a short time there 
was an amendment in the breathing and pulse — the as- 
phixia hue of the skin gave place to a natural colour, 
and the child recovered. He is at present a remarkable 
specimen of the most vigorous health. 

The third case was that of an infant born at eight and 
a-half months old ; the mother being at the time ill with 
a violent dysentery. The child moaned a good deal 



MORBUS C(ERULEUS OF INFANTS. 369 

immediately after its birth, as seven months' children 
generally do, but it appeared to do very well for a few 
days, so that my attention was not specially called to it 
by the monthly nurse. It was a week old when I was 
called upon to see it, with information that it was dying. 

I am very confident that no physician would have 
formed any other conclusion than that at which I arri- 
ved, upon seeing the infant — it appeared so far gone, 
that there was not the least expectation that it could 
recover. Nevertheless, I placed it in the inclined posi- 
tion, and on the right side — directed a leech to be put 
on the region of the heart, and told the nurse not to 
move it for six hours. The child recovered, and is 
now in excellent health. 

These are three successful cases which have been no- 
ticed within about two years. I have made use of the in- 
clined position on the right side for two other children, 
one of which was born at seven months and a-half. 
Both of them died. 

I have, with great deference for the judgment of my 
brethren, ventured to make the above relation of a kind 
of organic imperfection, which usually admits of no ra- 
tional treatment ; and I am not fully prepared to say, 
that the successful results of the three cases are to be 
confidently assigned to the position in which the chil- 
dren were placed, though I am strongly inclined to believe 
that, had they been laid on the left side, or had they 
continued to lie on the nurse's lap or in her arms, subject 
to be jolted and disturbed with every one of her move- 
ments, I should not have enjoyed the pleasure of seeing 
these infants recover. I very sincerely hope that some 
of my medical brethren will try the same method of 
treatment in the cases that may fall under their care, and 
if any success should follow, that they will make it 
known to the medical public, inasmuch as it is a subject 
in which any practitioner of midwifery must feel strong- 
ly interested, on account of the generally fatal conse- 
quences of all the severe (iases under the ordinary modes 
of managing them. 

I shall not close this article without mentioning the 
case of a new-born child, about twelve hours old — it 



370 MORBUS CCERULEUS OF INFANTS. 

was very small and thin. The father, who was a me- 
dical gentleman, told me he had never been able to feel 
any pulse in its wrists. It was dying with asphixia ; 
it expired very shortly after I saw it, and the body was 
examined. Upon a careful investigation, the auricles, 
with the septum, were perfectly formed ; but the ven- 
tricles were without any septum at all, so that they 
formed a single large ventricle, which gave origin to 
the pulmonary artery at one point, and at another to 
the aorta. 



THE END. 



u 



i 






V-^ ' 8 I "4 



%0,'i 



\' 












-^^ 



'^c.. 



I 8 i> '^ 



^ V^ 



^ '^ 






.0 O. 







■1 c> 



= .-."^ 



/■^ 






tea ^ -i o 






0" ^^-^ V^'/ ^> 



^^ 



■%'- 



,-i>^ 



'^^.. v^^ 



5 -;^. 



Jv^^x. 




.^^ 






<^.c,V 






^ .V 



,0 o. 



/'^^'^■'^^-^^^'^^^ 



N^^ '^^^ 






•' -^ 






4 ^ ^^> ^1. 



A^^> -, ^ ^<;'^^ 



\.. 



b^%, ^1-1 









:<% 






.vl^' 






.^0^ 



i 






.0^ 






v^^ 






-^ - V 



v.^ <?. ^_^^: 






oo^ 






-A 




#-\ 


-^■' -•■>■' 








>^'"-:.^:o.-,x*-°\^,..,\'*—y 












"/■ '> 



